Despite initiatives to reduce risks associated with non-steroidal anti-inflammatory drugs (NSAIDs), inappropriate prescribing remains common, causing harm to health and expense for the NHS, according to a study of prescribing data in England over the past decade.
A research team led by the University of Manchester quantified the prevalence, harms, and costs of "problematic" oral NSAID prescribing in high-risk groups. They pointed out that NSAIDs, widely prescribed worldwide, can cause gastrointestinal bleeding, myocardial infarction, stroke, and renal damage.
Hazardous Prescribing Events
The study identified five NSAID-specific hazardous prescribing events (HPE):
- Prescription without a co-prescription of a gastroprotectant for patients aged 65 or older
- No co-prescription of a gastroprotectant for patients with a history of peptic ulceration
- Co-prescription of an NSAID alongside warfarin or a directly acting oral anticoagulant
- Prescription to patients with heart failure
- Prescription to patients with chronic kidney disease
Using data from the national rollout of the pharmacist-led information technology intervention for medication errors (PINCER) in April 2020, the researchers ascertained a baseline prevalence of each HPE, along with prevalence data from 1060 general practices covering nearly 11 million patients. They estimated the harm associated with each of the five HPEs at patient level, expressed as quality adjusted life years (QALYs) lost, and the cost to the NHS of managing that harm. The researchers then estimated annual national levels of harm and costs for the general population of England.
The study, published in the BMJ, found that average QALYs lost per person ranged from 0.01 for previous peptic ulcer patients to 0.11 for those with chronic kidney disease. Average NHS costs increased by between £14 for patients with heart failure to £1097 for patients on anticoagulants.
Greatest Impact on Patients Taking Anticoagulants
The HPE with the greatest impact was observed in patients taking anticoagulants, with a modelled estimate over a decade of a total loss of 2143 QALYs at a cost of £25.41 million. Overall, the five HPEs caused a total loss of 6335 QALYs and cost the NHS £31.43 million over 10 years. The researchers concluded that more needs to be done to address NSAIDs as a continuing source of avoidable harm and healthcare costs, especially in high-risk groups.
Senior investigator Anthony Avery, professor of primary health care at the University of Nottingham and national clinical director for prescribing at NHS England, told Medscape News UK that in the real world, no intervention will completely stop hazardous prescribing, but that recent initiatives have reduced it.
Effective Interventions
The rollout of PINCER across the East Midlands was associated with a 24% reduction in hazardous prescribing linked to increased risk of gastrointestinal bleeding, and fewer NSAID prescriptions without protein pump inhibitors (PPI) to patients over 65 with a history of peptic ulcer (27% and 20% fewer, respectively).
"But surprisingly, we saw little impact on the prescribing of NSAIDs to patients receiving oral anticoagulants," Avery said. He hopes that the evidence from the study will help to convince prescribers and medicines optimisation teams of the hazards associated with the HPEs, particularly those that cause the most patient harm, prescribing to patients on oral anticoagulants and to patients with chronic kidney disease.
Addressing the Issue
Avery, a GP, acknowledged the difficulty in deterring doctors from such prescribing practices. "In my experience, GPs are naturally cautious in their prescribing, but when presented with a patient in pain they want to try and do something to help, and prescribing a medicine is often the first-line option," he said.
Also, even when provided with evidence of a risk of serious adverse effects, some patients make an informed decision to take an NSAID. They may have found that NSAIDs helped them in the past, or that other classes of medicines were ineffective or caused problems. "We recognise that doctors already take great care when making prescribing decisions, but sometimes the desire to help relieve a patient’s suffering may push us towards hazardous prescribing where the risks probably outweigh any likely benefits," he added.
New evidence may make a difference, however, as can well-designed safety alerts at the point of prescribing, whose use should be encouraged, according to Avery. "The approach we took in the PINCER intervention involved computer searches for specific types of hazardous prescribing, and then having a pharmacist work with the practice (using educational outreach and practical support) to tackle the problems identified," he explained. "We have shown that this works for certain types of hazardous prescribing."
Regulatory Warnings and Pharmacist Involvement
Regulatory authorities have issued various warnings concerning NSAIDs over the years and may consider the study's findings in deciding whether to issue new ones. Asked to comment by Medscape News UK, James Davies, Royal Pharmaceutical Society (RPS) director for England, said: "Improving the safety of NSAID prescribing requires a multipronged 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 said that 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."
The study was funded by the National Institute for Health and Care Research.