SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 2 | 13 NSAID vs NON NSAID USE OTC NSAID vs PRESCRIPTION NSAID USE GPA’s Non-PPI (Antacids, H2 blockers) 0.04 NS PPI NS NS Habits Smoker NS NS Alcohol use NS NS Indication Headache NS 0.001 Musculoskeletal NS NS Gastrointestinal .03 NS Other NS NS Pattern of use General advice NS NS Take with meals NS NS Frequency Daily NS NS Twice daily 0.002 NS Three times daily 0.0006 0.0003 Four times daily NS NS >Four times daily 0.0004 NS NSAID non-steroidal anti-inflammatory drug; OTC over the counter; GPA’s gastroprotective agents; PPI proton pump inhibitors; H2 histamine two; NS p-value>0.05; Discussion The South African Essential Drug List (SAEDL) proposes ibuprofen as an alternate analgesic to paracetamol in the first line management of pain 6 . No alternative is suggested for ibuprofen, and consequently the use of NSAID’s is common in South Africa. This study was conducted in two tertiary hospitals in the public health care environment where patterns of OTC NSAID use and their relationship to UGIT bleeds have not previously been characterised. During the study period, 70% (n=215) of patients who were admitted with UGIT bleeds used NSAID’s, 85% (n=183) of whom obtained their NSAIDs without a prescription. This is far more than in lower socioeconomic groups in first world countries, where 44% of patients admitted for UGIT haemorrhage used OTC NSAIDs 3 . The implication is that South African consumers, in particular low socioeconomic groups, NSAID’s are easily obtained and users are not being provided with adequate information to guide their decision making. In this study the three most significant risk factors for UGIT bleeds requiring hospital admission were advanced age, multiple medical co-morbidities and HIV infection. Age Advanced age itself has been shown to be an independent risk factor for UGIT bleeding as well as the most widely reported risk factor for UGIT bleed associated mortality 7 . Approximately 40-60% of NSAID consumers are over 60 years of age 8 , and up to 95% of elderly patients taking NSAID’s may obtain their medication OTC 9 . Of the individuals in this study older than 60 years of age, 33% (n=72) used NSAIDS of whom 79 % (n=57) obtained them OTC. In the Western world, the proportion of older patients suffering from UGIT bleeds has increased over recent years, mostly due to increased life expectancy and widespread NSAID use 7 . South Africa’s population older than 60 years of age has increased from 2.8 million (1996) to 4.1 million (2011) with projections of 7 million by 2030. Current socio-economic assessments estimate that 40% of the elderly population live in poverty, 38% rely on chronic medication and 28 % have no formal education 10 . In view of the fact that the risk of an UGIT bleed increases from 1.65 per 100 000 in patients <65 years to 5.7/100 000 in those >65 years and 12.7/100 000 in patients >75 years of age 11,12 together social and economic deficiencies the potential cost to SA healthcare is significant. Co-morbidities Epidemiological studies have demonstrated non- gastrointestinal comorbidities as independent risk factors for UGIB 13 . This association is evident in our population who take OTC NSAIDs as shown in Table 3. HIV Pain is a common symptom in people living with HIV and AIDS, occurring in 60% to 98% of patients in South Africa 14 . The South African Essential Drug List (SA EDL) treatment protocol for management of adult HIV and AIDS related pain recommends paracetamol and/or ibuprofen first line treatment. A study conducted at a primary health care facility in the city of Tshwane determined that ibuprofen was prescribed for 44% of patients and aspirin for 18% 15 . In addition 84% of prescriptions contained suboptimal drug dosages and an insufficient quantity of tablets to sustain the patient to the next appointment, consequently more than 25% of the sample population used OTC analgesia. In a study conducted at an HIV clinic in Houston Texas OTC NSAID’s accounted for 38% of the most commonly used medications 2 . All patients taking NSAID’s were prescribed gastroprotective agents (GPA’s) and the reported adverse drug reactions with concurrent antiretroviral treatment was 16 %, most were type II drug reactions. In our study 22 patients volunteered their HIV status as positive. All used NSAID’s, 20 as OTC NSAIDs and two used prescription NSAIDs. None of these patients took GPA’s. GPA’s are not listed in the SA EDL. Approximately 6.4 million people in South Africa live with HIV 16 , the potential cost of NSAID related UGIT bleeds is this population group is prodigious. Economics The cost of NSAID induced gastropathy has been best quantified in the elderly, a population group that on their own exhibit a high baseline rate of gastrointestinal bleeding 17 , and are the highest consumer group of NSAID’s 18 . Medical costs to treat the complications of UGIT bleeds in the elderly who use prescribed NSAIDs in the USA have been estimated at over $4 billion per year, and the annual cost attributed to lost work productivity and care exclusive of treatment expenditure amount to $5.65 billion 19 . A limitation of these cohort healthcare cost studies is that OTC medication use is not included as these are paid for by the patient, hence these costs are not captured in clinical billing databases. In South Africa more than 80% of the whole population do not have medical insurance, and studies have shown that many patients deem self funded primary health care visits as expensive as well as inconvenient 20 . South African consumers have also been shown to perceive generic medicines, obtained at no cost from public healthcare providers, as poor quality 19 . This places limitations on national medicine policies and may influence consumers to purchase specific, preferred brands of analgesics. Self-medication is predicted to demonstrate a constant compound annual growth rate of 2% with ibuprofen expected to show amongst the strongest growth 21 . In 2009 pharmaceutical manufacturers updated and innovated their products to accommodate this expanding group of consumers. The current competitive South African analgesic market is dominated by a non steroidal analgesic, Panado™ (paracetamol) with a brand retail value share of 34% (2013) up from 14% (2009), however REVIEW GPA’s Non-PPI (Antacids, H2 blockers) PPI Habits Smoker Alcohol use Indication Headache Musculoskelet Gastrointestin Other Pattern of use General advic Take with mea Frequency Daily Twice daily Three times d Four times dai >Four times daily NSAID non-steroidal the counter; GPA’s ga pump inhibitors; H2 h Discussion The South African Ess ibuprofen as an altern first line management for ibuprofen, and co common in South Afri tertiary hospitals in th where patterns of OT UGIT bleeds have not During the study p who were admitted w 85% (n=183) of who prescription. This is fa group in first world c dmitted for UGIT ha Th implication is that particular low socioec obtained and users ar information to guide t In this study the thr UGIT bleeds requirin age, multiple medical Age Adv nced age itself h risk factor for UGIT bl reported risk factor fo Appr ximately 40-60 years of age 8 , and up NSAID’s may obtain t individuals in this stu (n=72) used NSAIDS them OTC. In the We patients suffering fro r cent years, mostly widespread NSAID u than 60 years of age h to 4.1 million (2011) w Current socio-econo the elderly population medication and 28 % of the fact that the risk 1.65 per 100 000 in p those >65 years and REVIEW