Approximately 60% of NSAID users at high risk of NSAID complications do not receive adequate gastroprotection, according to a study by Vera Valkhoff and colleagues.

Patients on NSAIDs are at increased risk of upper gastrointestinal complications that range from dyspepsia to peptic ulcers and gastrointestinal bleeding. The risk of these events occurring in NSAID users is approximately four times that of the general population.

Credit: Credit: V. E. Valkhoff

Strategies employing gastroprotective agents to prevent these complications are recommended yet adherence to appropriate guidelines is reportedly low in everyday practice. Only NSAID users at high risk of upper gastrointestinal complications require prophylactic gastroprotection, which includes the use of PPIs, cyclo-oxygenase-2-selective inhibitors, histamine-2-receptor antagonsists or misoprostol.

Valkhoff and colleagues wished to establish whether there had been an increase in awareness among clinicians over time with regards to the prescription of gastroprotective agents.

...adherence to appropriate guidelines is reportedly low in everyday practice

Their dynamic, cohort study comprising 50,126 NSAID users aged ≥50 years analyzed data collected between 1996 and 2006. NSAID users were classified according to their risk factors for upper gastrointestinal complications. The researchers found that the correct prescription of gastroprotective agents in high-risk NSAID users increased during this period from 6.9% in 1996 to 39.4% in 2006, and that underprescription fell from 93.1% to 59.9%. In NSAID users at general risk of complications, overprescription of gastroprotective agents increased from 2.9% to 12.3%.

“We praise the positive developments that have been made in reducing the underprescription of gastroprotective agents over the past decade,” says Valkhoff, “however, we hope that progress will continue in the future because the prescription of recommended strategies was still unacceptably low in 2006, especially in vulnerable populations.” This was illustrated by the fact that 50% of NSAID users with a previous history of upper gastrointestinal complications (widely assumed to be the most important risk factor for NSAID complications) did not receive the necessary prophylaxis.

The authors hope to take their work forward by attempting to determine why general practitioners are nonadherent to the recommended guidelines. “If we understand the determinants for nonadherence we could improve the implementation of future guidelines,” explains Valkhoff. Estimating the influence of nonadherence on the prevalence of upper gastrointestinal adverse events is also an important goal for future research.