And just to pay attention to a few critical illnesses,
as we think about treatment of mild to moderate pain,
one is gastric ulcers.
There was a classic study that performed
endoscopy on patients who have been taking NSAIDs,
they found that there was some evidence
of gastric ulceration in 30% of those patients.
Those aren't usually serious
gastric ulcers that produce symptoms,
but nonetheless we always have
to be aware of chronic NSAID use
and the risk for a gastrointestinal ulcer
and gastrointestinal bleeding.
There is two opposing trends.
First of all, H. pylori has been more
recognized and now more is being treated.
So, that's driving the rate of peptic ulcers down.
However, more people are using
NSAIDs on a chronic basis,
particularly older adults
who are already at risk for ulcer.
That's driving the risk of ulcers up.
So, overall, the prevalence of
ulcers has remained about the same.
They account for up to 2.5% of all admissions.
But if you talk to patients and ask them,
has a doctor ever told you had
peptic ulcer in the past?
About 10% will say that
they had that diagnosis in the past.
So, there’s a disconnect there between admissions and
a broader number of patients who've been diagnosed with PUD.
Risk factors for peptic ulcer include older age,
low educational attainment, low family income,
history of smoking and, as I mentioned,
chronic NSAID use.
And the one I think we can do most
about as clinicians is chronic NSAID use.
What about kidney disease?
So, there is a link between
NSAID use and kidney disease,
but that doesn’t mean that if you're a 28-year-old
playing basketball and you sprain your wrist
and you take ibuprofen for
a week that you’re going to have
a significantly increased risk of kidney disease.
That's not going to happen.
Young healthy people,
it’s pretty safe to take intermittent NSAIDs.
However, among patients who are over 65,
taking NSAIDs, instead of acetaminophen,
is associated with 34% increase
in the risk of renal impairment,
and that is dramatically increased
if coronary artery disease is also present.
So, really, be cognizant of older adults
and adults with comorbid conditions that are
frequently associated with kidney disease.
NSAIDs can really do damage to
the kidney in those patients.
What about coronary heart disease?
So, this is a study of nearly 62,000 adults,
all of whom had a first-time
So, mostly men, mostly older, as you'd expect.
And so, what they're looking for here were two rates.
Among those patients with a myocardial infarction,
what were the rates of bleeding
among those who did and did not
receive an NSAID after their myocardial infarction?
What were the rate of cardiovascular events
among those who did and did not receive an NSAID?
And so, what they found not shockingly,
their bleeding is in green here,
that there was about twofold risk
in the risk of bleeding among patients with -- who received
an NSAID and had a history of myocardial infarction,
but there was also a 40% increase in the rate of recurrent
cardiovascular events associated with NSAID use as well.
So, this makes it appear that
NSAIDs may promote a higher risk of repeat cardiovascular
events among patients with known myocardial infarction.