NSAIDs and GI and Renal Complications

1
NSAIDs and GI and Renal Complications

• Lessons from Tennessee Medicaid population
  studies
• (and selected others)

2
Overview

• Upper GI complications of NSAIDs
• Age
• Dose/duration
• Corticosteroids
• Coumadin
• Renal complications
• Other

3
Age-specific peptic ulcer hospitalization rates
by sex and NSAID use, Saskatchewan, 1982-1986
Hospitalizations per1,000 person-years
Malenonusers
25
Femalenonusers
Maleusers
20
Femaleusers
15
10
5
0
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85 Age
Garcia Rodriguez et al, Epidemiology 1992
4
Hospitalizations for PUDTennessee Medicaid, age
65, 1984-86
Griffin et al Ann Intern Med 1991
5
Gastrointestinal Complicationsmeta-analysis 5
studies that included dose
Henry et al Br Med J 1996
6
Hospitalizations for PUDTennessee Medicaid, age
65, 1984-86
Smalley et al Am J Epidemiol 1995
7
Hospitalizations for PUDTennessee Medicaid, age
65, 1984-86
Smalley et al Am J Epidemiol 1995
8
Corticosteroids and NSAIDs

• Co-prescription 1-3 of elderly
• Similar to non-NSAID users
• Increases risk 13-15 fold over non-users
• Ulcer hospitalization 5-6 per 100 per year

9
Coumadin and NSAIDs

• Co-prescription 1-2 of elderly
• Similar to non-NSAID users
• Increases risk of GI bleeding 12 fold over
  non-users
• Ulcer hospitalization 3 per 100 per year

10
NSAIDs and Acute Renal Failure,Tennessee
Medicaid, aged 65, 1987-1991

• 1799 patients community acquired ARF
• 4.5 hospitalization per 1000 person-years
• Median length of stay 8 days
• 3 dialysis
• 30 day mortality 36

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NSAIDs and other risk factors for ARF

• 18 NSAID users
• Adjusted RR 1.58

• Other risk factors
• Older age
• Male gender
• Black race
• Nusing home resident
• Diuretics
• ACE inhibitors
• Other co-morbidity

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Individual NSAIDs

• NSAID RR 95 CI
• Ibuprofen 1.63 (1.23 to 2.08)
• Naproxen 1.03 (0.68 to 1.56)
• Ketoprofen 1.55 (0.54 to 4.45)

13
Ibuprofen dose and ARF Tennessee Medicaid, age
65, 1984-86
Griffin et al Am J Epidemiol 2000
14
Duration of NSAID use and ARF Tennessee
Medicaid, age 65, 1984-86
Griffin et al Am J Epidemiol 2000
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Other Considerations Upper GI and renal effect

• OTC drugs may be self-administered as previously
  prescribed (high dose)
• OTC drugs may be used for long duration
• Risk increases with combination of gt1 NSAID
• For GI events risk increases with aspirin use

16
Other Considerations Important other adverse
effects

• Hypertension
• Small increases in mean BP, large population
  effect
• Small bowel and lower GI bleeding
• Dyspepsia
• Increased health care costs
• Other