Inappropriate prevention of NSAID-induced gastrointestinal events among long-term users in the elderly

Although use of NSAIDs and aspirin (acetylsalicylic acid) is well known to be associated with gastrointestinal (GI) complications and potential mortality, these medications continue to be widely prescribed in the elderly. Age is a significant risk factor for NSAID-induced GI events; indeed, patients >75 years of age carry the highest risk and are similar in this respect to patients with a history of peptic ulcer. Prevention of NSAID-induced gastropathy is indicated in patients at risk. It is accepted that patients >60 years of age taking NSAIDs should participate in prevention strategies such as co-therapy with proton pump inhibitors (PPIs) or misoprostol, or use of cyclo-oxygenase (COX)-2 selective NSAIDs (also called coxibs). Although up to 33% of subjects with no risk factors who receive NSAIDs over-utilise GI preventive therapies, under-utilisation of gastroprotective therapy is more prevalent among those with risk factors, of which the most frequent is age. At least half of those at risk do not receive appropriate preventive therapy, either because they do not receive co-therapy with PPIs or misoprostol or are not treated with COX-2 selective NSAIDs, or because they receive co-therapy with antacids or histamine H(2) receptor antagonists, which are not effective. Adherence to the prescribed preventive therapy is an additional problem for those who are prescribed a PPI or misoprostol. Over 30% of patients are non-adherent and the lowest rate of non-adherence is associated with the first NSAID prescription, which increases the risk of ulcer bleeding compared with those who are fully adherent. Predictors of nonadherence include long-term use of NSAIDs and a high average daily dose of NSAIDs. Predictors of adherence include a history of upper gastrointestinal events, anticoagulant use, rheumatological disease and use of low-dose salicylates, among others. Another important aspect is self-medication; this is common in the elderly, who also have several risk factors for GI complications, and may be a factor in over one-third of all NSAID-related complications. In summary, aging is a key risk factor for GI complications in patients taking NSAIDs. Appropriate prevention strategies should be used in the elderly and those at risk; special attention should be paid to compliance and self-medication.