Consultants Forum

Interventions in Nursing Home Residents Receiving NSAIDs: Preventing GI Damage and Complications

Because of the serious concern about gastropathies associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), I initiated a review of the use of this drug class-including drug use, possible complications, and preventive measures-and interventions taken to prevent NSAID-associated gastropathies.

NSAID Use and Protective Measures

Appropriate medication use was based on the information in the Misoprostol Ulcer Complications Outcomes Safety Assessment (MUCOSA) and American College of Rheumatology guidelines. Residents were included in the project if they were receiving routine NSAID therapy, were receiving as-needed NSAID therapy under which the agents had been actually received for seven consecutive days, and had at least one of the following risk factors:

• Previous history of peptic ulcer disease
• History of gastrointestinal bleeding
• Age 65 years or older
• Concomitant corticosteroid therapy
• Presence of concomitant cardiovascular diseases
• Presence of other debilitating diseases (such as rheumatoid arthritis, multiple sclerosis, cancer, or chronic infectious diseases)

In eight nursing homes I served in Hawaii from June 1995 through January 1996, 27 residents were identified for inclusion. The mean number of risk factors per resident was 1.78, with 12 residents having one risk factor, nine having two risk factors, and six residents with three risk factors.

Ages ranged from 68 to 102 years, with a mean of 86.7 years. Two residents had histories of PUD, six residents had a history of cardiovascular disease, and 11 others had other concomitant debilitating diseases. Two residents were using corticosteroids while taking NSAIDs.

Most residents (20) were not on any type of therapy that might prevent GI complications in these at-risk patients. One resident was receiving histamine H₂ antagonist therapy; one was on routine antacids; three residents were on suboptimal doses of misoprostol; and two residents were receiving suboptimal doses of misoprostol in combination with H₂-blocker therapy.

Interventions

Based on these study results, I drafted a "Dear Doctor" letter (Figure 1) asking prescribers to consider adding GI preventive therapies to the drug regimens of these at-risk residents. My recommendations centered around instituting therapeutic doses of misoprostol or increasing doses in subtherapeutic regimens.

Results of Recommendations

For these 27 residents, the following results were noted:

• Misoprostol was added to the regimens of 11 residents.
• For one resident on suboptimal doses of misoprostol, the dose was increased.
• Physicians for six residents kept the protective regimens they already had in place.
• Physicians for two residents requested more information on prevention of NSAID-associated gastropathies.
• The remaining seven residents were maintained on NSAIDs without any protective measures.

Conclusion

This evaluation and intervention effort served not only to stimulate provision of appropriate pharmacotherapy for nursing home residents, but also to provide needed education of prescribers about available therapeutic options. The final outcomes are yet to be measured in terms of effects on GI complication rates and hospitalizations.

Joy H. Higa, RPh, FASCP
IPC Pharmacy/LTC
47-135 Heno Place
Kaneohe, HI 96744

Figure 1. Sample Letter to Physicians Requesting Consideration of Gastroprotective Therapies in Nursing Home Residents Receiving NSAIDs.

Dear Dr. ________:

Your patient is currently receiving:

____________ (NSAID)

____________ (NSAID with antiulcer medication)

Based on history and the presence of the following risk factors associated with NSAID-induced gastropathies, this patient may be at a greater risk of developing gastrointestinal bleeding (according to the MUCOSA study and American College of Rheumatology literature):

____ Previous history of peptic ulcer disease

____ Previous history of GI bleeding

____ Age 65 years or older

____ Concomitant corticosteroid therapy

____ Presence of cardiovascular disease

____ Presence of other debilitating disease (___________)

Since misoprostol (Cytotec) is the only agent currently indicated and proven to prevent NSAID-induced gastric and duodenal ulceration, would you kindly consider this patient therapy with this agent?

_____ Yes _____ No

To assure patient tolerability and decrease the incidence of diarrhea, the recommended starting dose of misoprostol is as follows:

• 100 mg b.i.d. after meals for one week, then increase to
• 200 mg b.i.d. after meals

If the resident cannot tolerate this usual adult dose of misoprostol, a dose lower than 200 mg can be used.

Thank you for your consideration of this request.

Sincerely,
Joy H. Higa, RPh
Consultant Pharmacist