Time‐trends in the prescribing of gastroprotective agents to primary care patients initiating low‐dose aspirin or non‐steroidal anti‐inflammatory drugs: a population‐based cohort study

Abstract

AIMSLow-dose aspirin (LDA) and non-steroidal-anti-inflammatory drugs (NSAIDs) both increase the risk of upper gastrointestinal events (UGIEs). In the Netherlands, recommendations regarding the prescription of gastroprotective agents (GPAs) in LDA users were first issued in 2009 in the HARM-Wrestling consensus. National guidelines on gastroprotective strategies (GPSs) in NSAID users were issued in the first part of the preceding. The aim of the present study was to examine time-trends in GPSs in patients initiating LDA and those initiating NSAIDs between 2000 and 2012. METHODSWithin a large electronic primary healthcare database, two cohorts were selected: (i) patients newly prescribed LDA and (ii) patients newly prescribed NSAIDs between 2000 and 2012. Patients who had been prescribed a GPA in the previous six months were excluded. For both cohorts, patients' risk of a UGIE was classified as low, moderate or high, based on the HARM-Wrestling consensus, and the presence of an adequate GPSwas determined. RESULTSA total of 37 578 patients were included in the LDA cohort and 352 025 patients in the NSAID cohort. In both cohorts, an increase in GPSs was observed over time, but prescription of GPAs was lower in the LDA cohort. By 2012, an adequate GPS was present in 31.8% of high-risk LDA initiators, vs. 48.0% of high-risk NSAID initiators. CONCLUSIONSDespite a comparable risk of UGIEs, GPSs are prescribed less in high-risk LDA initiators than in high-risk NSAID initiators. For both groups of patients, there is still room for improvement in guideline adherence. WHAT IS KNOWN ABOUT THIS SUBJECT• Low-dose aspirin and NSAIDs both increase the risk of serious upper gastrointestinal events. This risk can be reduced by concomitant prescription of a gastroprotective agent.• Various national and international guidelines have been issued regarding gastroprotective strategies in high-risk NSAID users, but recommendations on the prescription of gastroprotective agents in low-dose aspirin users were not issued until more recently. WHAT THIS STUDY ADDS• This study shows that the prescription of gastroprotective agents is far lower in high-risk lowdose aspirin users than in high-risk NSAID users, despite a comparable risk of upper gastrointestinal events in these high-risk groups. Less familiarity with the recommendations for low-dose aspirin users may play a role. However, even for NSAID users there is room for improvement in guideline adherence.• Of the environmental factors investigated, a change in the reimbursement policy of proton pump inhibitors had the clearest visible effect on prescription of gastroprotective agents in both low-dose aspirin and NSAID users, demonstrating the influence of such policy measures on guideline adherence.

Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review

“…A systematic review of preventable adverse drug events (pADEs) in ambulatory care found that gastrointestinal toxicity resulting from a failure to prescribe prophylactic agents with NSAIDs or antiplatelets was the most frequently identified adverse outcome in studies of pADEs requiring hospitalization [25]. A recent cohort study in a Netherlands primary care population found that adequate gastroprotection was absent in the majority of patients at high risk of experiencing a GI bleed [26]. The authors report that 52 % of those using NSAIDs and 68 % using low dose ASA were using them potentially inappropriately.…”

Characterizing Potentially Inappropriate Prescribing of Proton Pump Inhibitors in Older People in Primary Care in Ireland from 1997 to 2012

“…Research has shown a consistent upward trend in PPI use, up to a 13-times increase in the 12 years up to 2006 in Australia. [18][19][20][21] A Dutch study found a rise in PPI prescribing in individuals in primary care initiated on low-dose aspirin or a NSAID from 2000 to 2012 at all levels of risk of upper GI bleeding. 21 Regarding trends in maximal dose prescribing, a growing prevalence of high-intensity PPI use was noted in a Canadian study.…”

“…[18][19][20][21] A Dutch study found a rise in PPI prescribing in individuals in primary care initiated on low-dose aspirin or a NSAID from 2000 to 2012 at all levels of risk of upper GI bleeding. 21 Regarding trends in maximal dose prescribing, a growing prevalence of high-intensity PPI use was noted in a Canadian study. 22 Considering prescribing between 1997 and 2004 in this Canadian research, polypharmacy was associated with use of high doses, and older age was associated with lower odds, consistent with the current study.…”

Long‐Term Safety of a Coordinated Delivery Tablet of Enteric‐Coated Aspirin 325 mg and Immediate‐Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk

“…Proton pump inhibitor (PPI) therapy reduces the risk of aspirinassociated upper GI events and is recommended for patients at an increased risk [15,16]. However, several studies suggest that there are treatment gaps with the co-prescribed prophylactic PPI prescriptions and/or use [22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Specifically, when PPIs are co-prescribed, adherence rates are often suboptimal, leaving patients at risk for adverse upper GI outcomes [27,28,32,33,35].…”