Estrategia clínica para la prevención de los efectos adversos sobre el tracto digestivo de los antiinflamatorios no esteroideos

doi:10.1016/S0210-5705(03)70400-2

Gastroenterología y Hepatología

Volume 26, Issue 8, 2003, Pages 485-502

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Effects of Nabumetone compared with Naprosen on platelet agregation in patients with rheumatoid arthritis

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Administration of selective cyclooxygenase-2 inhibitor with warfarin does not increase blood loss following total knee arthroplasty (TKA)

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Cited by (32)

Safe prescription recommendations for non steroidal anti-inflammatory drugs: Consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)
2014, Gastroenterologia y Hepatologia
Este artículo señala las recomendaciones claves para una adecuada prescripción de antiinflamatorios no esteroideos a pacientes que presentan indicación de tratamiento con esta medicación, en base a la evidencia científica actual y teniendo en consideración aspectos de seguridad gastrointestinal y cardiovascular. Las recomendaciones se han consensuado por expertos designados por 3 sociedades científicas (Sociedad Española de Reumatología, Asociación Española de Gastroenterología y Sociedad Española de Cardiología), siguiendo una metodología Delphi a 2 rondas. Las áreas que se han tenido en cuenta engloban: eficacia, riesgo cardiovascular, riesgo gastrointestinal, riesgo hepático, riesgo renal, enfermedad inflamatoria intestinal, anemia, dolor postoperatorio y estrategias de prevención. Se propone un algoritmo de manejo de pacientes que recoge los aspectos fundamentales de las recomendaciones.
This article outlines key recommendations for the appropriate prescription of non steroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations
Safe prescription recommendations for non steroidal anti-inflammatory drugs: Consensus document ellaborated by nominated experts of three scientific associations (SER-SEC-AEG)
2014, Reumatologia Clinica
Este artículo señala las recomendaciones claves para una adecuada prescripción de antiinflamatorios no esteroideos a pacientes que presentan indicación de tratamiento con esta medicación, en base a la evidencia científica actual y teniendo en consideración aspectos de seguridad gastrointestinal y cardiovascular. Las recomendaciones se han consensuado por expertos designados por 3 sociedades científicas (Sociedad Española de Reumatología, Asociación Española de Gastroenterología y Sociedad Española de Cardiología), siguiendo una metodología Delphi a 2 rondas. Las áreas que se han tenido en cuenta engloban: eficacia, riesgo cardiovascular, riesgo gastrointestinal, riesgo hepático, riesgo renal, enfermedad inflamatoria intestinal, anemia, dolor postoperatorio y estrategias de prevención. Se propone un algoritmo de manejo de pacientes que recoge los aspectos fundamentales de las recomendaciones.
This article outlines key recommendations for the appropriate prescription of non steroidal anti-inflammatory drugs to patients with different musculoskeletal problems. These recommendations are based on current scientific evidence, and takes into consideration gastrointestinal and cardiovascular safety issues. The recommendations have been agreed on by experts from three scientific societies (Spanish Society of Rheumatology [SER], Spanish Association of Gastroenterology [AEG] and Spanish Society of Cardiology [SEC]), following a two-round Delphi methodology. Areas that have been taken into account encompass: efficiency, cardiovascular risk, gastrointestinal risk, liver risk, renal risk, inflammatory bowel disease, anemia, post-operative pain, and prevention strategies. We propose a patient management algorithm that summarizes the main aspects of the recommendations
Gastroprotection in NSAID and low-dose aspirin users: A cross-sectional study in primary care
2012, Gastroenterologia y Hepatologia
Citation Excerpt :
Risk factors for GI complications associated with NSAIDs are well defined and include a previous GI event (especially if complicated such as bleeding, perforation or obstruction), age, concomitant use of anticoagulants, corticosteroids, other NSAIDs including LDA, high-dose NSAID therapy and chronic debilitating disorders, especially cardiovascular disease.4 Based on these risk factors, several medical societies and scientific associations have issued guidelines for the prevention of GI complications in NSAID users.4–8 According to these guidelines, patients with an increased risk of GI complications should receive gastroprotection with misoprostol, proton-pump inhibitors (PPI) or high-dose histamine-2-receptor antagonists (H2RA).
Gastrointestinal (GI) complications are common side effects related to non-steroidal anti-inflammatory drugs (NSAID) and low-dose aspirin (LDA) use. The guidelines to prevent GI complications establish that patients at high risk should receive gastroprotection. However, different reports have suggested that these strategies are not greatly executed. To determine the prevalence of use of preventive strategies to reduce GI complications in NSAID and/or LDA users in primary care in Spain, we performed an observational, cross-sectional, multicentre study in which primary care physicians from Spain participated. From January 2009 to May 2009, physicians collected demographic, clinical and treatment data from the last visit in 2008 of the first 5 consecutive patients who met the selection criteria. A multivariate logistic regression was carried out to identify independent predictors of the preventive strategies used.
A total of 713 primary care physicians included 3357 patients: 68% NSAID users, 19.1% LDA users and 12.9% NSAID/LDA users. 31.5% of patients did not have a risk factor for GI complications, 25.6% had one risk factor and 42.9% had 2 or more risk factors. The overall prevalence of preventive strategy use was 75.8%. The prevalence of gastroprotection use increased with the number of risk factors.
The underutilization of gastroprotection in at-risk patients treated with NSAIDs is low and not as marked as those previously reported at the primary care level in other countries. We also found high rates of gastroprotection use in LDA users.
Las complicaciones gastrointestinales (GI) son un efecto secundario habitual relacionado con el uso de antiinflamatorios no esteroideos (AINE) y aspirina a dosis bajas (ADB). Las directrices para prevenir las complicaciones GI establecen que los pacientes con elevado riesgo deben recibir alguna forma de protección gástrica. Sin embargo, diversos informes sugieren que dichas estrategias no se llevan a cabo. Para determinar la prevalencia en la atención primaria española del uso de estrategias preventivas para reducir las complicaciones GI en los pacientes a los que se les ha prescrito AINE y ADB, se realizó un estudio observacional, transversal y multicéntrico en el que que participaron médicos de atención primaria. Desde enero a mayo de 2009, los médicos recogieron datos demográficos, clínicos y sobre tratamiento procedentes de la última visita en 2008 de los 5 primeros pacientes consecutivos que cumplían los criterios de selección. Se llevó a cabo una regresión logística multivariante para identificar los predictores independientes de las estrategias preventivas utilizadas.
Un total de 713 médicos de atención primaria incluyeron a 3357 pacientes: el 68% tomaba AINE, el 19,1% ADB y el 12,9% recibia AINE y ADB. El 31,5% de los pacientes no presentaba factores de riesgo de complicaciones GI, el 25,6% tenia uno y el 42,9% 2 o más factores de riesgo. La prevalencia total de uso de estrategias de prevención fue del 75,8%. La prevalencia del uso de gastroprotección incrementó con el número de factores de riesgo.
La infrautilización de protección GI en pacientes con alto riesgo tratados con AINE es baja y no es tan marcada como la que se notifica en la atención primaria de otros países. También se observó un uso elevado de gastroprotección en los pacientes que toman ADB.
Nonsteroid antiinflammatory agents: Pharmacodynamics, adverse drug reactions and indications in rheumatology
2011, Medicine
Citation Excerpt :
Otra revisión sistemática, analizando 112 estudios controlados aleatorizados con un total de 74.666 pacientes, incluidos los tres estudios con mayor muestra (CLASS, VIGOR y TARGET), concluye que excepto cuando los AINE-t se asocian a IBP, antiH2 o misoprostol, el uso de COXIB reduce las úlceras sintomáticas por AINE-t en un 50-90%16. En pacientes en tratamiento con COXIB, la adición de ácido acetilsalicílico en dosis antiagregante aumenta el riesgo de complicaciones ulcerosas, por lo que en estos casos podría ser más coste efectivo el tratamiento con AINE-t más gastroprotección11. Los COXIB también parecen ser seguros a corto plazo en pacientes con enfermedad inflamatoria intestinal17.
Medication reconciliation at hospital admission and discharge in an orthopedic surgery and traumatology department
2010, Revista Espanola de Cirugia Ortopedica y Traumatologia
Evaluar los resultados de un programa de conciliación e información de medicación al alta hospitalaria en un servicio de cirugía ortopédica y traumatología.
Se incluyeron los pacientes ingresados durante 2008 con mayor complejidad en su tratamiento domiciliario. Este se registró y se confirmó, mediante una entrevista con el paciente, la adherencia a éste, así como problemas relacionados con la medicación (PRM). A partir de la epicrisis, se concilió la medicación prescrita con el tratamiento ambulatorio y se resolvieron las discrepancias con el facultativo encargado. Por último, se entregó al paciente el listado completo de su medicación a partir del episodio asistencial y recomendaciones sobre su tratamiento, con la explicación verbal de este. Realizamos una encuesta de satisfacción a los traumatólogos para conocer el conocimiento del programa y su valoración.
Se seleccionaron 243 pacientes; en 102 (42%) se detectaron PRM. Las principales discrepancias se encontraron en fármacos antitrombóticos (25%) y analgésicos y antiinflamatorios (21%). Las discrepancias más frecuentes fueron la duplicidad terapéutica (53%) y las interacciones (27%). Los PRM se clasificaron según su gravedad: el 65% no habría causado daño al paciente y un 35% requeriría monitorización.
En cuanto a la encuesta de satisfacción, la valoración global del programa fue «muy buena» para el 100% de los facultativos.
La conciliación de medicación se ha mostrado como una estrategia útil para aumentar la seguridad de nuestros pacientes, en el marco de un sistema de reducción de riesgos para la salud y mejora de la calidad asistencial.
To evaluate the results of a medication reconciliation and drug information program at discharge in an orthopedic surgery and traumatology department.
Patients with more complexity in their home treatment, admitted in this facility during 2008 were included in the study. Preadmission regimens were recorded and the patents were asked about medication-related problems (PRM) and drug adherence. On the day of discharge, prescribed medication was reconciled with the outpatient treatment, resolving discrepancies with the prescribers. Finally, the patients were given a complete list of their medications after the care episode and recommendations on their treatment with oral explanation. We conducted a survey of the physicians to ask about their reconciliation program knowledge and their assessment.
243 patients were selected, in whom 102 (42%) PRMs were detected. The major discrepancies were found in antithrombotic drugs (25%) and analgesics and anti-inflammatory drugs (21%). The most frequent were: therapeutic duplication (53%) and interactions (27%). The PRMs were classified according to their severity: 65% would not have caused harm to the patient and 35% would require monitoring.
Regarding the survey, the overall evaluation of the program was "very good" for 100% of the physicians.
Medication reconciliation has proved to be a useful strategy for improving the safety of our patients as part of a system to reduce health risks and improving quality of care.
Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract
2010, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
After 6 months, the coxib arm had a 4.9% probability of recurrent ulcer bleeding, whereas patients on PPI co-therapy showed a 6.4% probability of recurrence (p = ns). As shown recently, the combination of a PPI + coxib provides the safest option in patients at the highest risk of developing a GI complication [71]. This combination is cost-effective [72], providing a 50% additional reduction in the incidence of upper GI complications already obtained with any of these strategies (NSAIDS + PPI vs coxib) alone.
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most widely prescribed medication in the world. Their main benefit derives from their anti-inflammatory and analgesic effect, but the use of these agents is not innocuous since they mainly increase the risk of gastrointestinal (GI) and cardiovascular complications compared with non-NSAID users. NSAIDs injures the upper and lower gut by depleting COX-1 derived prostaglandins and causing topical injury to the mucosa. The risk of upper GI complications varies, depending on the presence of one or more risk factors. Among them, the three main risk factors are prior history of peptic ulcer, the single most important risk factor, age, the most common, and concomitant aspirin use, due to their GI and cardiovascular implications. Those individuals at-risk should be considered for alternatives to NSAID therapy and modifications of risk factors. If NSAID therapy is required, patients at risk will need prevention strategies including co-therapy of NSAID with gastroprotectants (PPI or misoprostol) or the prescription of COX-2 selective inhibitors. The probable introduction of NO-NSAIDs in the market in the near future may open a new therapeutic option for patients with hypertension who need NSAIDs.

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Estrategia clínica para la prevención de los efectos adversos sobre el tracto digestivo de los antiinflamatorios no esteroideosRecomendaciones de la Asociación Española de Gastroenterología y de la Sociedad Española de Reumatología

First page preview

Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Lancet

Lancet

Lancet

Gastroenterology

Gastroenterology

Lancet

HELP NSAIDs study Lancet

Lancet

Am J Gastroenterol

Gastroenterology

Am J Med

Br J Anesthesia

Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis

Ann Intern Med

Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial

Ann Intern Med

Epidemiologic assessment of the safety of conventional nonsteroidal antiinflmmatory drugs

Am J Med

Association of adrenocorticosteroid therapy and peptic-ulcer disease

N Engl J Med

Corticosteroids and peptic ulcer: metaanalysis of adverse events during steroid therapy

J Intern Med

Steroids and risk of upper gastrointestinal complications

Am J Epidemiol

The risk of upper gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs, glucocorticoids, acetamonophen, and combinations of these agents

Arthritis Res

Hospitalisation for upper gastrointestinal bleeding associated with use of oral anticoagulants

Thromb Haemost

et al Peptic ulcer bleeding: accessory risk factors and interactions with non-steroidal anti-inflammatory drugs

Gut

Concurrent use of nosteroidal antiinnflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorragic peptic ulcer disease

Arch Intern Med

Concomitant coumarin-NSAID therapy and risk for bleeding

Ann Pharmacoth

A placebo controlled stady of interaction between nabumetone and acenocoumarol

Br J Clin Pharmacol

Comparison of upper gastrointestinal toxi-city of rofecoxib and naproxen in patients with rheumatoid arthritis

N Engl J Med

Adverse interactions between warfarin and nonsteroidal antiinflammatory drugs: mechanisms, clinical significance, and avoidance

Ann Pharmacother

Comparative inhibitory activity of rofecoxib, meloxicam, diclofenac, ibuprofen, naproxen on COX-2 versus COX-1 in healthy volunteers

J Clin Pharmacol

Celecoxib does not significantly alter the pharmacokinetics or hypoprotrombinemic effect of warfarin in healthy subjects

J Clin Pharmacol

Effects of Nabumetone compared with Naprosen on platelet agregation in patients with rheumatoid arthritis

Ann Rheum Dis

Administration of selective cyclooxygenase-2 inhibitor with warfarin does not increase blood loss following total knee arthroplasty (TKA)

Anesthesiology

Gastric adaptation occurs with aspirin administration in man

Am J Dig Dis

Gastric mucosal adaptation to diclofenac injury

Dig Dis Sci

Growth markers in the human gastric mucosa during adaptation to continued aspirin administration

J Clin Gastroenterol

Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/ perforation

Arch Intern Med

The influence of age gender, Helicobacter pylori and smoking on gastric mucosal adaptation to non-steroidal antinflammatory drugs

Aliment Pharmacol Ther

Individual nonsteroidal antiinflammatory drugs and other risk factors for upper gastrointestinal bleeding and perforation

Epidemiology

Nonsteroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons

Ann Intern Med

Risk of hospitalization for upper gastrointestinal bleeding associated with ketorolack, other nonsteroidal anti-inflammatory drugs, calcium antagonists, and other antihypertensive drugs

Arch Intern Med

Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons

Am J Epidemiol

Nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding identifying high-risk groups by excess risk estimates

Scand J Gastroenterol

Non-steroidal anti-inflammatory drugs and ulcer complications: a risk factor analysis for clinical decision-making

Scand J Gastroenterol

Risk factors for serious nonsteroidal-induced gastrointestinal complications: regression analysis of the MUCOSA trial

Fam Med

Nitrovasodilators, low-dose aspirin, nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding