Underutilization of preventive strategies in patients receiving NSAIDs

Background. Multiple treatment guidelines for non-steroidal anti-inflammatory drugs (NSAIDs) suggest that patients with one or more risk factors for NSAID-associated upper gastrointestinal (UGI) ulcer complications should be prescribed preventive strategies such as acid-suppressive drugs, misoprostol or cyclooxygenase (COX)-2-specific inhibitors to reduce their risk of serious ulcer complications. The purpose of the present study was to evaluate the extent to which new NSAID users receive recommended preventive strategies and to assess the association between risk factors and a prescription of acid suppressive drugs or misoprostol. Method. A retrospective observational cohort study was conducted using the Integrated Primary Care Information (IPCI) database, a longitudinal database of electronic general practitioner patient records in The Netherlands. The study population comprised all new NSAID users, defined as users of non-specific NSAIDs, COX-2-preferential NSAIDs and COX-2-specific inhibitors, during the period from January 1996 to April 2002. Subjects were excluded if they had an H-2-receptor antagonist (H(2)RA), proton pump inhibitor (PPI) or misoprostol prescription in the 3 months prior to the first NSAID prescription. Preventive use of acid-suppressive drugs or misoprostol was identified by the coprescription for these drugs on the same day (+/-2 days) as the NSAID prescription. The drug use for each patient was validated as having a preventive indication by reviewing the physician-recorded symptoms and diagnoses. Risk factors for UGI ulcer events were defined as age >65 yr, UGI history (gastroduodenal ulcer, UGI bleeding, dyspepsia) and concomitant medications (anticoagulants, aspirin, oral corticosteroids). The study population comprised 69648 new NSAID users. Results. Overall, 7.9% of NSAID users received a preventive strategy (6.6% received a gastroprotective agent and an additional 1.3% received COX-2-specific inhibitors). Patients using preventive drugs had higher odds of having one or more UGI risk factors than patients without preventive drugs [adjusted odds ratio (OR) 1.78, 95% confidence interval 1.66-1.92]. Despite the greater rate of preventive drug prescriptions in patients who may have been at higher risk, 86.6% of patients with one risk factor and 81.2% with two or more risk factors received no preventive strategies. In contrast to non-specific NSAIDs, patients who received a prescription for a COX-2-specific inhibitor had significantly lower adjusted odds (OR=0.22) of having H(2)RA/PPI or misoprostol coprescribed. Conclusions. Although patients who are treated with preventive strategies have higher odds of having gastrointestinal risk factors than those not prescribed preventive therapies, the majority (>80%) of patients with one or more gastrointestinal risk factors do not receive the recommended NSAID treatment regimen of a COX-2-specific inhibitor or NSAID+H(2)RA/PPI or misoprostol and are therefore undertreated.