NSAIDS & PPI’S: Reducing the risk

1. Farrukh Javid NSAIDS & PPI’S: Reducing the risk

3. Why such an interesting topic? • Noticed many patients had NSAIDs on repeat rx without gastroprotection • Confused about when/whom to give PPI cover to • Felt like I was prescribing it by the bucketload...

4. “Medicine is the art of entertaining the patient, as the body heals itself.” • Voltaire

5. “A witty saying proves nothing.” • Voltaire

6. Risks of chronic NSAID use • GI – bleeding, ulceration • Renal impairment • Cardiovascular- MI, stroke risk

7. Risks of chronic NSAID use (2) • BNF: • Hepatic damage, alveolitis, pulmonary eosinophilia, pancreatitis, visual disturbances, Stevens-Johnson syndrome, and toxic epidermal necrolysis. • Induction of or exacerbation of colitis or Crohn’s disease. • Aseptic meningitis

8. Guidelines • Inconclusive • Conflicting advice – who should be on PPI • Difficult to interpret – What constitutes “long term” NSAID use

10. When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor. In either case, these should be co-prescribed with a PPI, choosing the one with the lowest acquisition cost.

11. The audit... • April 2011 • Total list size = 6427 • Searched for patients who: • were on NSAIDs on their repeat Rx OR had recently had more than 2 prescriptions of an NSAID on their acute list in the last 3 months • BNF 10.1 minus exceptions • AND • Not on PPI or not had one issued

12. Initial results • 64 patients in total • Manually analysed patient records to determine whether or not the patient required gastroprotection • Common reasons for exclusion: • Not using NSAID regularly • On ranitidine/have since been put on PPI • Patient left/deceased

13. 47 Patients remaining • Sent a letter...

14. Round 1 • 26 patients replied to initial letter within 6 weeks – started on omeprazole • 21 patients remaining • Some patients saw a GP to discuss the medication • 4 patients declined PPI

15. Re-audit • Repeated search end of June • 10 patients remaining • 2 patients tried PPI but c/o nausea • Re-sent (modified) letter to remaining patients • 2 patients not replied, ie-not on PPI

16. Outcomes/Recommendations • Patient/Doctor education • Not all NSAIDs are equally risky • Highest risk: Azapropazone • Intermediate risk: piroxicam/ketoprofen /indometacin/diclofenac/naproxen • Low risk: Ibuprofen • Consider topical NSAIDs if appropriate • Use the lowest effective dose for the shortest duration of treatment

17. Outcomes/Recommendations • Consider risk factors when prescribing: • Age, co-morbidity, CV/renal risk • Other medications, eg – aspirin, warfarin, ACE-i • Previous GI adverse effects/ulcers • Regular review of NSAID use • More frequent review if more risk factors • Consider coxibs if GI risk factors (but increase CV risk) • PPI’s aren’t risk free either!

18. Extension of audit • Looking at patients with risk factors that are on NSAIDs. Eg: • Age • Co-morbidity • Previous GI adverse effects • Taking aspirin/warfarin/ACE-i etc. • How many patients having BP/renal function checked on regular basis

19. Questions?

20. References • Primary Prevention of Adverse Gastroduodenal Effects from Short-Term Use of Non-Steroidal Anti-Inflammatory Drugs by Omeprazole 20 mg in Healthy Subjects: A Randomized, Double-Blind, Placebo-Controlled Study. Dig Dis Sci (2008) 53:2059–2065 • Co-prescribing of proton pump inhibitors among chronic users of NSAIDs in the UK. Rheumatology 2008;47:458–463 • Management of NSAID-Induced Gastrointestinal Toxicity: Focus on Proton Pump Inhibitors. Drugs 2009; 69 (1): 51-69 • http://bnf.org/bnf/bnf/current/60265.htm • http://www.npc.nhs.uk/rapidreview/?p=293 • http://www.npc.nhs.uk/qipp/resources/qipp_document_jan2011_version1.1_march11_final.pdf • http://www.cks.nhs.uk/nsaids_prescribing_issues/evidence/supporting_evidence/prevention_of_gi_adverse_effects • http://www.nice.org.uk/nicemedia/live/11926/39557/39557.pdf