UTILIZATION OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS IN QUEBEC: ADHERENCE TO THE CANADIAN CONSENSUS ON PRESCRIPTION GUIDELINES
Main Article Content
Keywords
Pharmacoepidemiology, drug utilization, non-steroidal anti-inflammatory drugs, COX-2 inhibitors, prescription guidelines
Abstract
Background
Adverse events associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) have led to the publication of Canadian prescription guidelines. Prescription practices following the publication of these guidelines and the introduction of COX-2 inhibitors in the Quebec formulary of reimbursed medications remain largely unexplored.
Objectives
To compare the prevalence of contra-indications and selected risk factors for NSAID-toxicity among COX-2 inhibitor users and non-selective NSAID users.
Methods
A case-control analysis was conducted in a random sample of Quebec adult drug plan members who were treated with celecoxib (n=42,422 cases), rofecoxib (n=25,674 cases), full-dose (anti-inflammatory doses) of non-selective NSAIDs (n= 9,673 cases), or low-dose NSAIDs (n=2,745 controls) in the yearData were obtained from the Quebec prescription and medical services databases (RAMQ).
Results
Patients with a history of gastropathy were more likely to be prescribed COX-2 inhibitors than low-dose NSAIDs; the odds ratios were 1.73 (95%CI: 1.56-1.91) and 1.49 (1.33-1.66), respectively for celecoxib and rofecoxib. Corresponding results for concomitant use of anticoagulants were 1.95 (1.34-2.83) for celecoxib and 1.87 (1.26-2.77) for rofecoxib, and for use of corticosteroids they were 1.29 (1.08-1.54) and 1.23 (1.01-1.49). Conversely, patients with the following characteristics were less likely to receive COX-2 inhibitors than low-dose non-selective NSAIDs: age 75+ (OR=0.64; 0.56-0.72 for celecoxib, OR=0.48; 0.76-0.99 for rofecoxib), hypertension (OR=0.83; 0.75-0.92 for celecoxib, OR=0.87; 0.77-0.97 for rofecoxib), and concomitant use of diuretics (OR=0.72; 0.63-0.82 for celecoxib; OR=0.77; 0.66-0.89 for rofecoxib).
Conclusion
Patients with risk factors for NSAID gastropathy were more likely prescribed COX-2 inhibitors, while the presence of other contra-indications led to the prescription of low-dose non-selective NSAIDs. However, 12.7% of users of full-dose non-selective NSAIDs were age 75+ and 12.0% had a history of gastropathy, which are considered important risk factors for adverse events.
References
2. Tannenbaum H, Peloso PMJ, Russell A, Marlow B. An evidence-based approach to prescribing NSAIDs in the treatment of osteoarthritis and rheumatoid arthritis: The Second Canadian Consensus Conference. Can J Clin.Pharmacol. 2000; 7(suppl.A): 4-16A.
3. Simon SL, Weaver LA, Graham YD et al. Anti- inflammatory and upper gastrointestinal effects of celecoxib in rheumatoid arthritis: A randomized controlled trial. JAMA 1999; 282: 1921-1928.
4. Emery P, Zeilder H, Kvien KT et al. Celecoxib versus diclofenac in long-term management of rehumatoid arthritis: randomised double-blind comparison. The Lancet 1999; 354: 2106-2111.
5. Silverstein FE et al. Gastrointestinal toxicity with celecoxib vs. nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. JAMA 2000; 284: 1247-1255.
6. Geba GP, Weaver AL, Polis AB et al. Efficacy of rofecoxib, celecoxib, and acetaminophen in osteoarthritis of the knee. JAMA 2002; 287: 64-71.
7. Day R, Morrison B, Luza A et al. Randomized trial of the efficacy and tolerability of the COX-2 inhibitor rofecoxib vs ibuprofen in patients with osteoarthritis. Arch. Intern. Med. 2000; 160:1781-1787.
8. Bombardier C, Laine L, Reicin A, et al. For the VIGOR Study Group. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N. Engl. J. Med. 2000; 343: 1520-1528.
9. Langham JM, Jensen MD, Watson JD, et al. Adverse upper gastrointestinal effects of rofecoxib compared with NSAIDs. JAMA 1999; 282: 1929-1933.
10. Watson JD, Harper ES, Zhao PL, et al. Gastrointestinal tolerability of the selective Cyclooxygenase-2 (COX-2) inhibitor rofecoxib compared with nonselective COX-1 and COX-2 inhibitors in osteoarthritis. Arch. Intern. Med. 2000; 160: 2998-3003.
11. Scott JL, Lamb MH. Profil d’un nouveau médicament: Rofecoxib. Adis International, Drugs 1999; 58: 409-506.
12. Singh DK, Goldstein JL, Pettitt D, Burke TA, Schwartz S. Relative gastrointestinal toxicity of specific and nonspecific cyclooxygenase inhibitors within a high-risk managed care population. Ann Rheum Dis 2001;60 (Suppl 1):82.
13. Mamdani M, Rochon PA, Juurlink DN, Kopp A, Anderson GM, Naglie G, et al. Observational study of upper gastrointestinal haemorrhage in elderly patients given selective cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti- inflammatory drugs. BMJ 2002;325:624-629.
14. Laine L, Connors LG, Reicin A, Hawkey CJ, Burgos-Vargas R, Schnitzer TJ, Yu Q, Bombardier C. Serious lower gastrointestinal clinical events
with nonselective NSAID or coxib use. Gastroenterology. 2003 Feb;124(2):288-92.
15. Jüni P, Rutjes AWS, Dieppe PA. Are selective COX-2 inhibitors superior to traditional non- steroidal anti-inflammatory drugs? BMJ 2002; 324: 1287-1288.
16. Skelly MM, Hawkey CJ. Potential alternatives to COX-2 inhibitors. Editorials BMJ 2002; 324: 1289-1290.
17. Pathak A, Boveda S, Defaye P, et al. Celecoxib- associated torsade de pointes. Letter. Ann.Pharm. 2002; 36: 1290-1291.
18. Letters for Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 2001; 286: 2808-2813.
19. Lichtenstein RD, Wolfe MM. COX-2 selective NSAIDs: New and Improved? JAMA 2000; 284:1297-1299.
20. The University of British Columbia Department of Pharmacology & Therapeutics. Therapeutics initiative evidence based drug therapy. COX-2 inhibitors update: Do journal publications tell the full story? Therapeutic letter 2001-2002; 43 (Nov/Dec/Jan).
21. Peterson LW, Cryer B. COX-1 Sparing NSAIDs- Is the enthusiasm justified? JAMA 1999;282:1961-1963.
22. Jones R. Efficacy and safety of COX-2 inhibitors.New data are encouraging but the risk: benefit ratio remains unclear. BMJ 2002; 325: 607-608.
23. Graham DJ, Campen D, Cheetham C et al. Risk of acute cardiac events among patients treated with cyclooxygenase-2 selective and non-selective nonsteroidal antiinflammatory drugs. Pharmacoepidemiol. & Drug Safety 2004; 13: S 287(abstr.).
24. McCormack JP, Rangno R. Digging for data from the COX-2 trials (Letter). CMAJ 2002; 166:1649-1650.
25. Donabedian A. Aspects of medical care administration. Harvard University Press, Cambridge 1973.
26. Rothman KJ, Greenland S. Modern Epidemiology. 2nd Edition. 1998. Lippincott- Raven Publishers.
27. Von Korff M, Wagner E, Saunders K. A chronic disease score from automated pharmacy data. J. Clin. Epidemiol. 1992;45: 197-203.
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