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Prescribing non-steroidal anti-inflammatory drugs (NSAIDs) in high-risk patients is a “source of avoidable harm”, study authors have reported.
Writing in The BMJ on 24 July 2024, researchers provided evidence that prescribing of NSAIDs to people at high risk of harm could have caused more than 6,000 lost years of good health across the population of England over a ten-year period.
The study looked at data from the ongoing ‘Pharmacist-led information Technology Intervention for Medication Errors’ (PINCER) project, which began in 2018, and also at prevalence data from 1,060 general practices in England, representing a total of 10.9 million patients.
The research focused on patients in five high-risk groups who had been prescribed NSAIDs: older adults (aged 65 years or older) with no gastroprotection (n=1,350,000); people also taking oral anticoagulants (n=246,000); or people with heart failure (n=88,000); chronic kidney disease (n=137,000); or people with a history of peptic ulcers (n=83,000).
According to the analysis, the most common type of hazardous prescribing event (HPE) was in the group of older adults without gastroprotection, with a prevalence of 1.7/1,000 patients.
In this group, 1,929 quality-adjusted life years (QALYs) were lost over ten years (95% credibility interval 1,416–2,425), with an estimated cost to the NHS of £2.46m (95% credibility interval £0.65m–£4.68m) over that period.
However, the results also showed that the greatest harm and cost was among people taking oral anticoagulants. Although the prevalence rate of HPEs in this group was smaller (0.37/1,000 patients), it resulted in 2,143 QALYs lost (894–4,073), with an associated cost of £25.41m (£5.25m–£60.01m).
Taking into account all five high-risk patient groups, the report estimated a total QALY loss of 6,335 years (4,471–8,658) and an NHS cost of £31.43m (£9.28m–£67.11m) over ten years.
NSAIDs are a class of medicines used to treat pain, fever and other inflammatory processes, including aspirin, ibuprofen and naproxen. As with all medicines, they can cause side effects, the most common of which include stomach irritation and/or pain; bleeding from the stomach, bowels or back passage; rashes and respiratory problems. If used long term, they can cause kidney problems.
According to the authors, most previous studies of a similar nature have focused on the short-term costs of admission to hospital for gastrointestinal bleeds related to NSAIDs.
“Key strengths of [our] study are the estimation of the harm and NHS costs incurred by NSAID prescribing across range of common gastrointestinal, cardiovascular and renal harms possible in key groups at high risk for adverse events,” they said.
“These factors included longer term harms and costs, such as those associated with gastrointestinal rebleeding, and acute kidney injury associated increases in the risk of chronic kidney disease progression.”
They added: “Despite quite large improvements in high-risk prescribing of NSAIDs in the past 10–15 years, more work needs to be done.”
However, they add: “In practice, reducing NSAID prescribing on an individual level by prescribers is challenging because it depends on how much pain a patient is in, how well they respond to NSAIDs, and how well they respond to other analgesics or interventions.”
Commenting on the study, Alice Oborne, consultant pharmacist in safe medication practice and trust medication safety officer at Guy’s and St Thomas’ NHS Foundation Trust, said: “[The study] adds to previous, shorter duration studies of hazardous NSAID prescribing as data over ten years are included.
“The hazardous prescribing criteria reflect well known areas of risk, and are also reflected in the NHSBSA medicines safety indicators. Few other studies have considered the prevalence, cost and harm from NSAID use, particularly in chronic kidney disease or heart failure.
“Reassuringly, the prevalence of hazardous prescribing, cost and harm were relatively low, suggesting that progress has been made toward safer prescribing, in the right direction, with preferential use of safer NSAIDS (e.g. naproxen),” she added.
James Davies, director for England at the Royal Pharmaceutical Society (RPS), said the paper “highlights the economic impact of prescribing NSAIDs in higher-risk patient groups”.
“Improving the safety of NSAID prescribing requires a multi-pronged approach that educates and supports prescribers on the risk, as well as uses the skills of pharmacists in the primary care team, to help identify higher risk patients and prescribing scenarios,” he explained.
“This further emphasises why the RPS is continuing to call for pharmacists in primary care to be supported to deliver structured medication reviews, to identify polypharmacy and opportunities for deprescribing in priority patient groups.
“Pharmacists can work collaboratively with patients, and include the wider multidisciplinary team where needed, to discuss alternative medication or consider non-pharmacological options if appropriate,” he added.
