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NSAIDs for elderly a sore spot

Experts disagree on dangers and benefits of long-term use. By Erin Mayo.

The use of non-steroidal anti-inflammatories amongst older Australians is cause for alarm, states a report from the University of Sydney, which found that people over 70 were more likely to be on these medications for a prolonged period of time.

Current guidelines recommend that people use NSAIDS, such as celecobix (popular brand name Celebrex), ibuprofen (Nurofen) and diclofenac (Voltaren) for the shortest time possible.

However, the report states that the length and frequency that older Australians were taking these medicines was in stark contrast to those guidelines.

“We found in our population of older men, that they were using NSAIDs for an average of five years,” says lead author Danijela Gnjidic, University of Sydney faculty of pharmacy. “It was a long period of time rather than a short time as indicated by the guidelines, and they were more likely to be used on a regular basis rather than ‘as required’.”

Long term and regular use of anti-inflammatories can cause serious complications, including gastrointestinal ulcers and bleeding and a reduction in kidney function.

“Australian and international guidelines suggest NSAIDs should be used for short-term treatment and taken as needed,” Gnjidic says. “This is clearly not what is happening in reality.

“Prescribing doctors are not adhering to the specific guidelines for the safe use of NSAIDs in older people.”

On the other hand, Dr Richard Kidd, chairman of the Healthy Ageing Committee at the Australian Medicine Association, says the reality is not so black and white, and that in many cases the benefits outweigh the risks of the medications.

“The actual rate of prescribing anti-inflammatories and anti-rheumatic medicines has dropped, so there has been a change in general practice around the prescribing of these medications,” Kidd says. “But having said that, people over the age of 70 are the group that are suffering from more degenerative and more chronic diseases than any other group because, of course, as we get older we accumulate these problems.

“Overall, GPs are prescribing less of these medications, but they are probably being more appropriate by and large at the prescribing.

“Someone over the age of 70 with significant arthritis has significant pain, which greatly interferes with their ability to exercise and perform daily activities. So if we can control their pain to some extent and reduce the inflammation and swelling, we can greatly increase their quality of life, increase their mobility, reduce the risk of falls and delay their admission into aged-care facilities.

“These are very painful conditions, and if you don’t manage the pain people become bedridden, or they end up in an aged-care facility or they fall because of the pain.

“[And] although these guidelines are in place,” Kidd continues, “they have probably been developed more in relation to younger people who have intermittent flare-ups of osteo-arthritis, and in those situations a short course is appropriate.

“And then the reality is, that our patients tell us they do get real benefits every day from taking their anti-inflammatories, and that they have a better quality of life and can be more mobile as a result.”

Gnjidic concedes that some of the usage issues surrounding NSAIDs may be patient-driven.

“It may be patients who feel strongly about taking these medications,” she says. “If you start using a medication and you’ve been on it for years, there may be a fear to stopping these medicines.”

Patients may also be accessing NSAIDs over-the-counter, without knowing the side effects of long-term usage or possible interactions.

“That’s one of the reasons the AMA has been opposed to anti-inflammatories being over-the-counter medications,” Kidd says, “because there is no guarantee that a busy pharmacist is going to ask the right questions, or that even if they do, the patient is going to be able to tell the pharmacist what medications they are on.

“One of the big problems with anti-inflammatories is if they are taken in conjunction with ACE-inhibitors, which are taken for blood pressure or heart failure, and especially if you combine that with a diuretic, you can wipe out the kidneys and have severe renal failure quickly.

“If anti-inflammatories were available only on prescription, there is a much better chance that the treating doctor, who should know the other medications the person is on, will be aware of that triple whammy threat,” he explains. I see that as a real concern.”

The Pharmaceutical Society of Australia, however, strongly believes that pharmacists are well placed to help ensure that NSAIDs are taken appropriately and that at-risk patients are identified.

“Pharmacists are perfectly placed through their role in the dispensing process and in the sale of over-the-counter medicines to further reduce inappropriate NSAIDs use,” PSA national president Grant Kardachi argues. “Pharmacists are training in quality use of medicines which is one of the central objectives of Australia’s National Medicines Policy.

“Under the definition, QUM means selecting management options wisely, choosing a suitable medicine if a medicine is considered necessary, and using medicines safely and effectively. All of those come into consideration when pharmacists advise on NSAIDs usage.

“In addition,” Kardachi continues, “pharmacists are well placed to undertake medication reviews of patients through pharmacist-initiated MedsChecks in the pharmacy and Home Medicine Review – a more in-depth review in the patient’s home initiated by their GP.”

Sydney Uni’s Gnjidic adds: “Health professionals need to work together, to firstly determine the most effective way to manage medicine use, or to minimise any potential side effects. She also recommends that the use of NSAIDs be limited and that options such as paracetamol should be a first defence.

“Our study also showed that people who were using NSAIDs were more likely to be using other potentially interactive medicines, which is a cue that these medicines have to be reviewed to minimise any side effects,” Gnjidic argues.

In any case, Kidd says the issue of overuse also highlights a greater problem – the length of hospital waiting lists.

“More people are having hip replacement or joint replacements, and if you get your knees or hips replaced, quite often you can come off opioid medications and anti-inflammatories,” he says. “But unfortunately if you don’t have private health cover and you can’t afford a private operation, to get a hip replacement through the public system could take a very long time, if [it ever happens]. So there is a problem with accessing joint replacements, which in some cases are going to be more appropriate interventions than long-term anti-inflammatories.”

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