E-DRUG: Many NSAID users who bleed don't know when to stop

[srahmad@essential.org]

E-DRUG: Many NSAID users who bleed don't know when to stop
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British Medical Journal (www.bmj.com) Vol 316 Editorial Feb 14 1998 

Many NSAID users who bleed don't know when to stop
Uncomprehending "adherence" is dangerous
Andrew Herxheimer

Upper gastrointestinal bleeding and perforation are common and serious
adverse effects of non-steroidal anti-inflammatory drugs. About a third 
of all ulcer bleeding in older people is associated with these drugs(1,2); 
the same may apply to perforation. The most important predisposing 
influences are the type and dose of drug (and use of two non-steroidal 
anti-inflammatory agents together), which can increase the risk up to 
20-fold. Other risk factors include prior ulcer,(3) anticoagulants, 
systemic corticosteroids,(4) smoking,(5) alcohol consumption,(6) and old 
age.(1)(3) Some of these are independent, so that treatment with 
non-steroidal anti-inflammatory drugs increases an already high risk. As 
we look for ways of lowering the risk of bleeding in patients using 
non-steroid anti-inflammatory drugs, an ingenious investigation from 
Newcastle offers a new lead.(6) 

Wynne and Long studied 50 consecutive patients admitted to hospital with 
an acute gastrointestinal bleed who had taken any of four commonly used
non-steroidal anti-inflammatory drugs in the preceding three days and 100
controls from local practices - matched for age, sex, drug, and dosage - 
who had not bled.(6) All patients were visited at home by a nurse to 
assess their knowledge of their arthritis treatment. The nurse asked 
whether the patients had received any information about possible side 
effects of the drug, if so from where, and what they had been advised to 
do if side effects occurred. She asked the index patients, "Did you have 
any stomach problems, such as indigestion or pain before your stomach 
bleed?" and the controls, "Have you had any stomach problems, such as 
indigestion or pain?" The nurse also asked the patients to estimate how 
much of the prescribed dose they actually took and, if it was less than 
prescribed, why so. 

It turned out not only that the patients who had bled into the gut knew 
less about the side effects of their drugs or what to do when they 
occurred than did the controls but also that they stuck more closely to 
the prescribed dosage. Fewer index patients (16%) than controls (41%) 
remembered having been told of the potential side effects or about what 
to do if they developed an adverse effect (4% versus 21%). "Full 
compliance" was commoner among the index patients (96%) than among the 
controls (70%). Furthermore, 18 (36%) of the index patients had had 
epigastric pain before the bleed and all but two had continued to take the 
drug, whereas only 15 (15%) of the controls had had dyspepsia, of whom 10 
had reduced their intake. 

Perhaps this study should be interpreted cautiously: it was fairly small; 
patients with a complication may be more likely to claim that they were 
inadequately warned; and dyspepsia is widely accepted to be a poor guide 
to ulceration - though this has not been critically examined in relation 
to use of non-steroidal anti-inflammatory drugs. Nevertheless, it looks 
as if ignorance about side effects led to failure to recognise warning 
symptoms and to inappropriate compliance. Ten of the 16 patients who had 
pain but continued their drug and bled might not have bled if they had 
stopped the drug at once. Ten bleeds fewer out of 50 would be a useful 
reduction. 

As the authors say, we need effective methods of increasing patients'
knowledge and understanding of side effects - and this applies not only 
to non-steroidal anti-inflammatory drugs. In particular we must try to 
ensure that patients and doctors share the same goals in medicine taking 
and move from compliance to concordance.(7,8) Establishing what works best 
will take time and effort. But for a start, whenever doctors, pharmacists, 
and nurses see a patient who is using a non-steroidal anti-inflammatory ]
drug they could check whether the patient understands two things. Firstly, 
they should understand that the drug is for symptomatic relief and should 
be used only when arthritic pain or inflammation is troublesome. Some 
patients with severe rheumatoid arthritis may have to take the drug all 
the time, but most others do not. Prescribers and patients should not aim 
at complete relief by using high doses because this increases the risk of 
damaging the gut; they should accept partial relief. Secondly, they should 
know that stomach pain or indigestion is a signal to stop taking the drug 
if possible; if this is not possible, they and the doctor should consider 
whether to reduce the dose. 

Of 21 patient information leaflets for oral non-steroidal 
anti-inflammatory drugs, nine tell the patient to stop taking the drug if 
such symptoms occur; the others say "tell your doctor" or something 
similar.* The points about symptomatic relief and using moderate doses 
whenever possible are almost completely absent. The Medicines Control 
Agency should insist that the leaflets are clear and consistent on these 
points.

*I did the survey in spring 1997 and I thank Andrew King and David Scott 
for obtaining leaflets not in the ABPI Compendium of Patient Information 
Leaflets 1996-97. 

Andrew Herxheimer Adviser 
Health Action International-Europe, 
9 Park Crescent, London N3 2NL 
email: Andrew_Herxheimer@compuserve.com 

References
1 Somerville K, Faulkner G, Langman M. Non-steroidal anti-inflammatory 
drugs and bleeding peptic ulcer. Lancet 1986;i:462-4. 
2 Faulkner G, Prichard P, Somerville K, Langman M J S. Aspirin and 
bleeding ulcers in the elderly. BMJ 1988;297:1311-3. 
3 Laporte J-R, Carn� X, Vidal X, Moreno V, Juan J. Upper gastrointestinal 
bleeding in relation to previous use of analgesics and non-steroidal 
anti-inflammatory drugs. Lancet 1991;337:85-9. 
4 Piper O M, Ray W A, Daugherty J R, Griffin M R. Corticosteroid use and 
peptic ulcer disease: role of non-steroidal anti-inflammatory drugs. Ann 
Intern Med 1991;114:735-40. 
5 Henry D, Dobson A, Turner C. Variability in the risk of major 
gastrointestinal complications from non-steroidal anti-inflammatory drugs. 
Gastroenterology 1993;105:1078-88. 
6 Wynne H A, Long A. Patient awareness of the adverse effects of 
non-steroidal anti-inflammatory drugs (NSAIDs). Br J Clin Pharmacol 
1996;42:253-6. 
7 Mullen P D. Compliance becomes concordance. BMJ 1997;314:691-2. 
8 Marinker M. From compliance to concordance: achieving shared goals in 
medicine taking. BMJ 1997;314:747-8. 

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