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Nonsteroidal Anti‐Inflammatory Drugs, Gastroprotection, and Benefit–Risk
Author(s) -
Moore Robert Andrew,
Derry Sheena,
Simon Lee S.,
Emery Paul
Publication year - 2014
Publication title -
pain practice
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.899
H-Index - 58
eISSN - 1533-2500
pISSN - 1530-7085
DOI - 10.1111/papr.12100
Subject(s) - medicine , number needed to harm , adverse effect , number needed to treat , nonsteroidal , aspirin , proton pump inhibitor , pain relief , intensive care medicine , anesthesia , relative risk , confidence interval
Background Gastroprotective agents ( GPA ) substantially reduce morbidity and mortality with long‐term nonsteroidal anti‐inflammatory drugs ( NSAID s) and aspirin. Objective To evaluate efficacy of NSAID s, protection against NSAID ‐induced gastrointestinal harm, and balance of benefit and risk. Methods Free text searches of PubMed (December 2012) supplemented with “related citation” and “cited by” facilities on PubMed and Google Scholar for patient requirements, NSAID effectiveness, pain relief benefits, gastroprotective strategies, adherence to gastroprotection prescribing, and serious harm with NSAID s and GPA . Results Patients want 50% reduction in pain intensity and improved fatigue, distress, and quality of life. Meta‐analyses of NSAID trials in musculoskeletal conditions had bimodal responses with good pain relief or little. Number needed to treat ( NNT s) for good pain relief were 3 to 9. Proton pump inhibitors ( PPI ) and high‐dose histamine‐2 receptor antagonists (H 2 RA ) provided similar gastroprotection, with no conclusive evidence of greater PPI efficacy compared with high‐dose H 2 RA . Prescriber adherence to guidance on use of GPA with NSAIDS was 49% in studies published since 2005; patient adherence was less than 100%. PPI use at higher doses over longer periods is associated with increased risk of serious adverse events, including fracture; no such evidence was found for H 2 RA . Patients with chronic conditions are more willing to accept risk of harm for successful treatment than their physicians. Conclusion Guidance on NSAID s use should ensure that patients have a good level of pain relief and that gastroprotection is guaranteed for the NSAID delivering good pain relief. Fixed‐dose combinations of NSAID plus GPA offer one solution.