Non-steroidal anti-inflammatory drugs--prescribe with caution.

VERY year 20 million prescriptions are written for non-steroidal anti-inflammatory drugs in Great Britain (about 5% of all National Health Service prescriptions).' A recent study has shown that for 85%o of patients on long term non-steroidal anti-inflammatory drugs the treatment was initiated by their general practitioner.2 However, reports from the Committee on Safety of Medicines claim that this group of drugs is responsible for 25% of all yellow card reports on suspected adverse reactions, the most common being gastrointestinal reactions.' Hypertension, heart failure, renal impairment and upper gastrointestinal irritation can all be aggravated by these drugs. The above study revealed that 46%o of patients on long-term non-steroidal anti-inflammatory drugs had one or more of these conditions and that 38/o of the study population were taking medicines which could interact with non-steroidal anti-inflammatory drugs.2 Somerville and colleagues3 claim that elderly patients admitted with a bleeding peptic ulcer were twice as likely to be taking a non-steroidal anti-inflammatory drug other than aspirin when compared with an age-sex matched group of controls. Experimental studies suggest this is because the drugs interfere with the synthesis of the prostaglandins that inhibit gastric acid secretion.4 Non-steroidal anti-inflammatory drug ingestion has also been shown by endoscopy to cause gastro-mucosal erosions in 31%o of patients with osteoarthritis or rheumatoid arthritis.5 Although Jick and colleagues have questioned the association between non-steroidal anti-inflammatory drugs and perforated peptic ulcer,6 this study has been criticized for using a self-selected group and not controlling for age.7'8 Experience with benoxaprofen and the osmosin formulation of indomethocin has shown that it is crucially important when assessing adverse reactions to non-steroidal anti-inflammatory drugs to focus on the way in which the drugs affect older people, for whom they are commonly prescribed. The chronic nature of rheumatoid and osteoarthritis means that the drugs may be taken continuously for long periods and in the case of benoxaprofen, serious adverse reactions occurred after up to nine months on treatment. Perforated peptic ulcer has been shown to be more common in elderly females and several studies have shown a strong association between ingestion of these drugs and perforated peptic ulcer in the elderly.9"0 Post-menopausal women may be particularly at risk because of a lack of circulating oestrogens and progesterones which would normally increase the production of mucus in the stomach." Steele and colleagues2 have shown that a significant proportion of patients. receiving repeat prescriptions for non-steroidal anti-inflammatory drugs were elderly …