1. NSAIDs and GI and Renal Complications Lessons from Tennessee Medicaid population studies (and selected others)

2. Overview Upper GI complications of NSAIDs –Age –Dose/duration –Corticosteroids –Coumadin Renal complications Other

3. Age-specific peptic ulcer hospitalization rates by sex and NSAID use, Saskatchewan, 1982-1986 Female nonusers Male nonusers Female users Male users 152025303540455055606570758085+ Age 20 15 10 5 0 25 Hospitalizations per 1,000 person-years Garcia Rodriguez et al, Epidemiology 1992

4. Hospitalizations for PUD Tennessee Medicaid, age 65+, 1984-86 Griffin et al Ann Intern Med 1991

5. Gastrointestinal Complications meta-analysis: 5 studies that included dose Henry et al Br Med J 1996

6. Hospitalizations for PUD Tennessee Medicaid, age 65+, 1984-86 Smalley et al Am J Epidemiol 1995

7. Hospitalizations for PUD Tennessee Medicaid, age 65+, 1984-86 Smalley et al Am J Epidemiol 1995

8. Corticosteroids and NSAIDs Co-prescription 1-3% of elderly –Similar to non-NSAID users Increases risk 13-15 fold over non-users Ulcer hospitalization: 5-6 per 100 per year

9. Coumadin and NSAIDs Co-prescription 1-2% of elderly –Similar to non-NSAID users Increases risk of GI bleeding 12 fold over non-users Ulcer hospitalization: 3 per 100 per year

10. NSAIDs and Acute Renal Failure, Tennessee Medicaid, aged 65+, 1987-1991 1799 patients community acquired ARF –4.5 hospitalization per 1000 person-years –Median length of stay 8 days –3% dialysis –30 day mortality 36%

11. NSAIDs and other risk factors for ARF 18% NSAID users –Adjusted RR 1.58 Other risk factors –Older age –Male gender –Black race –Nusing home resident –Diuretics –ACE inhibitors –Other co-morbidity

12. Individual NSAIDs NSAIDRR 95% CI Ibuprofen 1.63 (1.23 to 2.08) Naproxen 1.03(0.68 to 1.56) Ketoprofen1.55 (0.54 to 4.45)

13. Ibuprofen dose and ARF Tennessee Medicaid, age 65+, 1984-86 Griffin et al Am J Epidemiol 2000

14. Duration of NSAID use and ARF Tennessee Medicaid, age 65+, 1984-86 Griffin et al Am J Epidemiol 2000

15. Other Considerations: Upper GI and renal effect OTC drugs may be self-administered as previously “prescribed” (high dose) OTC drugs may be used for long duration Risk increases with combination of >1 NSAID For GI events risk increases with aspirin use

16. Other Considerations: Important other adverse effects Hypertension –Small increases in mean BP, large population effect Small bowel and lower GI bleeding Dyspepsia –Increased health care costs Other