Prescribing
Harm from NSAIDs prescribed to high-risk groups
A study aimed to quantify the prevalence and harms of problematic oral NSAID prescribing in England, in high-risk groups over a 10 years period. High-risk groups included people: ≥65yrs with no gastro-protection; taking oral anticoagulants; with heart failure; with chronic kidney disease (CKD); with a history of peptic ulcer.
Outcome measures included the prevalence of hazardous prescribing events and discounted quality adjusted life years (QALYs) lost.
QALY losses were observed when NSAIDs were prescribed in all high-risk groups. Mean QALYs per person were between 0.01 (95% credibility interval (CI) 0.01 to 0.02) lower with history of peptic ulcer, to 0.11 (0.04 to 0.19) lower with CKD. The greatest impact was in people concurrently taking oral anticoagulants: 2143 (894 to 4073) QALYs lost.
Prevalence of hazardous prescribing events per 1000 patients ranged from 0.11 in people who have had a peptic ulcer to 1.70 in older adults. The most common hazardous prescribing event (older adults with no gastroprotection) resulted in 1929 (1416 to 2452) QALYs lost.
NSAIDs continue to be a source of avoidable harm in these five high-risk populations.
Suggested WiseGP actions:
1. Wherever possible avoid NSAID prescribing in the above high-risk groups.
2. Consider an audit of NSAID prescriptions on repeat, to identify patients in high-risk groups, then arrange a medication review for them.
Read more about the research informing this GEM: https://www.bmj.com/content/386/bmj-2023-077880
Prescribing antihypertensives to people aged 80 years and above is as likely to lead to a serious fall as to prevent a stroke/myocardial infarction
A cohort study used anonymised data from the electronic health records of patients in England, to examine whether patients prescribed antihypertensives were more likely to experience a serious adverse event sooner, compared to those not prescribed them.
Antihypertensive prescriptions were associated with an increased risk of hospitalisation/death from falls, syncope, acute kidney injury, electrolyte abnormalities and gout. However, the absolute risk of these events was low, increasing in frail and elderly patients.
In patients aged 80-89 years, analysis found 1 serious fall would occur each year in every 33 people treated. Other research suggests 1 stroke/myocardial infarction would be prevented for every 38 people treated with antihypertensives aged >85 years.
Suggested WiseGP actions:
1. Share this evidence with your colleagues involved in the holistic care of your frail, elderly population, to support individualised management plans.
2. Recommend colleagues reviewing new admissions to nursing homes/ performing medication reviews for elderly patients in your practice consider deprescribing antihypertensives where appropriate.
3. Consider a quality improvement project for your foundation doctor/ registrar or practice pharmacist, addressing potential over-treatment of hypertension in your frail, elderly patient population- could they review a cohort in one of your nursing homes?
Read more about the research informing this GEM here:
Correlation between antibiotic use and colorectal cancer
A case-control study aimed to investigate the association between antibiotic use and colorectal cancer (1).
Almost 8,000 people with colorectal cancer were matched to 5 controls. People with previous cancer, on immunosuppressants and with predisposing conditions, such as polyposis syndromes, were excluded.
In people >50 years, antibiotic use was associated with an estimated 9% higher risk of colon cancer. (Adjusted Odds Ratio 1.09 (95% CI 1.01, 1.18), p=0.029) - These statistics mean the true value could be anywhere between 1% and 18%.
In people <50 years, antibiotic use was associated with an estimated 49% higher risk of colon cancer. (Adjusted Odds Ratio 1.49 (95% CI 1.07, 2.07), p=0.018) - These statistics mean the true value could be anywhere between 7% and 107%. The power of findings was limited by low numbers in this younger cohort.
An earlier case-control study found antibiotic use was associated with an increased colon cancer risk in a dose-dependent fashion, with risk observed after minimal use, being greatest in the proximal colon and with antibiotics that had anti-anaerobic activity (2).
WiseGP Action
Before the next spike in winter viral illnesses that prompt many antibiotic requests, have a practice educational meeting, where latest antibiotic guidelines for common infections are covered and techniques to manage difficult consultations discussed. You could use the opportunity to update practice texts to be sent to patients to support safety netting and prescribing decisions.
Read more about the studies informing this GEM below.
Increased risk of VTE when taking both NSAIDs and hormonal contraception
It’s well established that oral contraceptives can increase venous thromboembolism (VTE) risk. There is also longstanding evidence that NSAIDs are associated with an increased risk of VTE. Have you ever considered their combined risk?
New research has demonstrated that in combination, the risks of hormonal contraception and NSAIDs are additive. Compared with non-use of NSAIDs, the adjusted number of extra VTE events per 100, 000 women over the first week of NSAID treatment was 4 in women not using hormonal contraception, 23 in women taking an NSAID and high risk hormonal contraception* and 11 with concomitant use of an NSAID and medium risk hormonal contraception**.
WiseGP Actions:
Consider advising against combined use of NSAIDS and moderate/ high risk hormonal contraception, particularly in women who are smokers or have a raised body mass index.
Consider discussing NSAIDs at a practice meeting/ tutorial.
What are your team’s prescribing habits?
Has the shift away from opiates increased your teams’ reliance on NSAIDs for pain management? (See GEMs on chronic pain for further discussion points)
Are clinicians who perform contraceptive reviews advising on the combined risk of NSAIDs with hormonal contraception?
Read more about the evidence informing this GEM here: https://www.bmj.com/content/382/bmj-2022-074450
*High risk contraception - combined oestrogen and progesterone patch, vaginal ring, and tablets containing 50 µg ethinyl oestradiol, or desogestrel, gestodene, drospirenone, or the anti-androgen cyproterone.
** Medium risk contraception - all other combined oral contraceptives as well as the depot injection.
