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• W2039557632 abstract "Non-variceal upper gastrointestinal (UGI) bleeding and perforation due to peptic ulcer disease have been linked to 2 main factors, Helicobacter pylori infection and/or nonsteroidal anti-inflammatory drug (NSAID)/aspirin use. Because the prevalence of H pylori infection is progressively decreasing in Western countries,1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection: the Maastricht IV/Florence Consensus Report.Gut. 2012; 61: 646-664Crossref PubMed Scopus (1844) Google Scholar NSAID/aspirin use is becoming the main factor associated with UGI complications. As these changes are occurring, an aging population suffering from various arthritis conditions is being widely prescribed NSAIDs for the treatment of pain and inflammation. On the basis of well-established scientific evidence from both randomized clinical trials and observational studies, international guidelines recommend that patients with risk factors for NSAID treatment should receive cotherapy with gastroprotective agents (proton pump inhibitors [PPIs] or misoprostol or high-dose famotidine). These guidelines also recommend the prescription of a cyclooxygenase-2 selective inhibitor alone instead of a traditional NSAID plus a gastroprotective agent, or a cyclooxygenase-2 selective agent plus a PPI if the patient's gastrointestinal risk is very high.2Zhang W. Doherty M. Arden N. et al.EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005; 64: 669-681Crossref PubMed Scopus (742) Google ScholarThe implementation of these guidelines should reduce the occurrence of UGI complications in at-risk patients treated with NSAIDs, but the actual impact of these recommendations in clinical practice is far from being well documented in most countries, although various studies with different methodological approaches to this question have been carried out in the last 10 years. To date, 2 critical aspects have been identified and investigated when evaluating the implementation of guidelines for the prevention of gastrointestinal complications in NSAID users, the rate of prescription of preventive therapies to at-risk patients receiving NSAIDs and the patient's adherence to the prescribed gastroprotective agents. In this issue, Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar report that failure to renew prescriptions for gastroprotective agents for patients on continuous NSAID therapy is another critical aspect that requires consideration when planning strategies to reduce the gastrointestinal damage induced by NSAIDs. Without considering these 3 critical steps, strategies for minimizing the risk of UGI complications in patients treated with NSAIDs will fail. Therefore, doctors should prescribe the appropriate preventive therapy, patients should adhere to that treatment, and eventually doctors need to persistently prescribe the appropriate therapy for patients on chronic long-term treatment with NSAIDs, as is the case for many elderly patients with osteoarthritis or rheumatoid arthritis.The first study reporting some data on these issues came from the Netherlands and showed very low, I would say alarmingly low, rates of prescription of preventive therapies for at-risk patients receiving NSAIDs.4Sturkenboom M.C. Burke T.A. Dieleman J.P. et al.Underutilization of preventive strategies in patients receiving NSAIDs.Rheumatology (Oxford). 2003; 42: 23-31Crossref Google Scholar The authors reported that 86.6% of patients on NSAIDs with 1 risk factor and 81.2% with 2 or more risk factors did not receive prevention strategies for the UGI tract. Since then, several studies have also reported low rates of gastroprotective therapies in NSAID users, ranging from a low 3.8% in Nova Scotia5Hartnell N.R. Flanagan P.S. MacKinnon N.J. et al.Use of gastrointestinal preventive therapy among elderly persons receiving antiarthritic agents in Nova Scotia, Canada.Am J Geriatr Pharmacother. 2004; 2: 171-180Abstract Full Text PDF PubMed Scopus (20) Google Scholar to 27.2% in the United States6Abraham N.S. El-Serag H.B. Johnson M.L. et al.National adherence to evidence-based guidelines for the prescription of nonsteroidal anti-inflammatory drugs.Gastroenterology. 2005; 129: 1171-1178Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar and 60.2% in France.7Thiéfin G. Schwalm M.S. Underutilization of gastroprotective drugs in patients receiving non-steroidal anti-inflammatory drugs.Dig Liver Dis. 2011; 43: 209-214Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, according to more recent studies, these low rates have improved with time, as has been demonstrated in the Netherlands. Correct prescription for high-risk NSAID users rose from 6.9% to 39.4% in 10 years (1996–2006) in one study8Valkhoff V.E. van Soest E.M. Sturkenboom M.C. et al.Time-trends in gastroprotection with nonsteroidal anti-inflammatory drugs (NSAIDs).Aliment Pharmacol Ther. 2010; 31: 1218-1228Crossref PubMed Scopus (41) Google Scholar and from 39.6% to 69.9% in another study (2001–2007).9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar Adherence of patients to the prescribed treatment is another key point. Reported rates of nonadherence broadly range from 9% to 80%, although the most recent studies from Europe reported levels of approximately 70% or higher.9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar, 10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Suboptimal adherence to gastroprotectants (defined as adherence <80% of the prescribed days) has been associated with a 2-fold to 4-fold increase in the risk of UGI bleeding in patients receiving NSAIDs.10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 11Lanas A. Polo-Tomás M. Roncales P. et al.Prescription of and adherence to non-steroidal anti-inflammatory drugs and gastroprotective agents in at-risk gastrointestinal patients.Am J Gastroenterol. 2012; 107 (Erratum in: Am J Gastroenterol 2012;107:639): 707-714Crossref PubMed Scopus (33) Google ScholarIn this issue, Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar have formulated a clearer perspective on another aspect of underprescription of gastroprotective agents (PPIs) in NSAID users that has not been described to date. Because many patients take NSAIDs over the long-term, renewal of prescription for gastroprotectants is essential to keep the risk of UGI complications low. Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar conducted a retrospective, observational, longitudinal study by using a validated electronic database covering a representative panel of general practitioners in France. Patients were included if they were at risk for gastrointestinal events and had received an NSAID prescription associated with an initial concomitant PPI prescription. Le Ray et al found that the probabilities of still being prescribed a PPI concomitantly with an NSAID at 1 and 2 years after study inclusion were 77.5% and 68.3%, respectively. Risk factors for nonpersistence were a change in the NSAID molecule, female gender, and absence of gastrointestinal side effects. PPIs were reintroduced in 50% of the cases within 6 months after the patient stopped taking it, without a specific reason being reported in 70% of the cases. The rate of gastrointestinal adverse events was higher in patients lacking an optimal PPI prescription. The authors conclude that physicians omit the renewal of prescriptions for gastroprotective agents in one-third of at-risk patients chronically treated with NSAIDs; this omission is associated with an increased rate of gastrointestinal complications, although this last point (complications) was not actually demonstrated in the study.Far from being bad news for the scientific community and for patients, as could be understood by the authors' conclusion, the findings in this new study represent, in my opinion, a confirmation of the current, increasing tendency for correct implementation of the guidelines recommending gastroprotection in at-risk NSAID/aspirin users, a tendency that has been observed in several European countries.8Valkhoff V.E. van Soest E.M. Sturkenboom M.C. et al.Time-trends in gastroprotection with nonsteroidal anti-inflammatory drugs (NSAIDs).Aliment Pharmacol Ther. 2010; 31: 1218-1228Crossref PubMed Scopus (41) Google Scholar, 9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar, 10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 11Lanas A. Polo-Tomás M. Roncales P. et al.Prescription of and adherence to non-steroidal anti-inflammatory drugs and gastroprotective agents in at-risk gastrointestinal patients.Am J Gastroenterol. 2012; 107 (Erratum in: Am J Gastroenterol 2012;107:639): 707-714Crossref PubMed Scopus (33) Google Scholar, 12van Soest E.M. Sturkenboom M.C. Dieleman J.P. et al.Adherence to gastroprotection and the risk of NSAID-related upper gastrointestinal ulcers and haemorrhage.Aliment Pharmacol Ther. 2007; 26: 265-275Crossref PubMed Scopus (69) Google Scholar Furthermore, the rates of renewal of PPI prescriptions for NSAID users reported by Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar may represent an underestimation of appropriate prescription therapy to these patients, because a significant proportion of patients (10.4%) who were not prescribed a renewal of a PPI received a cyclooxygenase-2 selective inhibitor instead. On the basis of current guidelines,2Zhang W. Doherty M. Arden N. et al.EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005; 64: 669-681Crossref PubMed Scopus (742) Google Scholar this is a valid and appropriate strategy in at-risk patients. Furthermore, in half of the patients who experienced interruption of the PPI cotherapy, it was reintroduced within 6 months after its cessation, although without a specific reason reported in 70% of the cases. Perhaps the doctors recognized the absence of gastroprotectants with the renewal of the NSAID prescription, or perhaps the patients reported dyspepsia or other symptoms such as gastroesophageal reflux disease. In any case, although the study by Le Ray et al was not specifically designed to evaluate UGI complications, the authors report very few nonserious adverse events (mostly dyspepsia cases and 18 cases of peptic ulcers) in this cohort of patients followed for up to 2 years. These data agree with recent reports showing a dramatic decrease in the number of hospitalizations because of peptic ulcer bleeding and perforation,13Laine L. Yang H. Chang S.C. et al.Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009.Am J Gastroenterol. 2012; 107: 1190-1195Crossref PubMed Scopus (201) Google Scholar even in countries where the prevalence of H pylori infection in elderly people is still high, as are the prescription rates of NSAIDs and PPIs.14Lanas A. García-Rodríguez L.A. Polo-Tomás M. et al.Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice.Am J Gastroenterol. 2009; 104: 1633-1641Crossref PubMed Scopus (389) Google Scholar I believe that taken together, all available data clearly demonstrate that the battle is being won on the side of patient safety, at least in Western countries. The prevalence of H pylori infection is decreasing, and the appropriate prescription of safer NSAID therapy is growing toward optimal levels. At the same time, between one-fourth and one-third of at-risk patients do not receive appropriate preventive NSAID therapy or are not adherent to the prescribed regime; new efforts need to be implemented. Similarly, we need to maintain or even increase the levels of continuing medical education as an essential aspect of our professional career. We must also implement new devices and/or formulas to recall appropriate prescriptions in a world where almost anyone in our profession is electronically “online.” Furthermore, new pill formulations of NSAIDs combined with gastroprotectants are emerging into the market, which will increase the appropriate prescription for and adherence of patients to both NSAIDs and gastroprotective therapy.As often occurs in medicine, new challenges arise when it seems that we are achieving other goals. The battle to prevent UGI complications in NSAID users is moving in the right direction, but a new challenge is now clear. NSAIDs also induce complications from the lower gastrointestinal tract (small bowel and colon). This field retains many open questions, one of the most important of which is identifying appropriate therapies to prevent damage in both the upper and lower gastrointestinal tracts in NSAID users. The implementation of these measures in clinical practice will require new efforts, education, and imagination. Non-variceal upper gastrointestinal (UGI) bleeding and perforation due to peptic ulcer disease have been linked to 2 main factors, Helicobacter pylori infection and/or nonsteroidal anti-inflammatory drug (NSAID)/aspirin use. Because the prevalence of H pylori infection is progressively decreasing in Western countries,1Malfertheiner P. Megraud F. O'Morain C.A. et al.Management of Helicobacter pylori infection: the Maastricht IV/Florence Consensus Report.Gut. 2012; 61: 646-664Crossref PubMed Scopus (1844) Google Scholar NSAID/aspirin use is becoming the main factor associated with UGI complications. As these changes are occurring, an aging population suffering from various arthritis conditions is being widely prescribed NSAIDs for the treatment of pain and inflammation. On the basis of well-established scientific evidence from both randomized clinical trials and observational studies, international guidelines recommend that patients with risk factors for NSAID treatment should receive cotherapy with gastroprotective agents (proton pump inhibitors [PPIs] or misoprostol or high-dose famotidine). These guidelines also recommend the prescription of a cyclooxygenase-2 selective inhibitor alone instead of a traditional NSAID plus a gastroprotective agent, or a cyclooxygenase-2 selective agent plus a PPI if the patient's gastrointestinal risk is very high.2Zhang W. Doherty M. Arden N. et al.EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005; 64: 669-681Crossref PubMed Scopus (742) Google Scholar The implementation of these guidelines should reduce the occurrence of UGI complications in at-risk patients treated with NSAIDs, but the actual impact of these recommendations in clinical practice is far from being well documented in most countries, although various studies with different methodological approaches to this question have been carried out in the last 10 years. To date, 2 critical aspects have been identified and investigated when evaluating the implementation of guidelines for the prevention of gastrointestinal complications in NSAID users, the rate of prescription of preventive therapies to at-risk patients receiving NSAIDs and the patient's adherence to the prescribed gastroprotective agents. In this issue, Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar report that failure to renew prescriptions for gastroprotective agents for patients on continuous NSAID therapy is another critical aspect that requires consideration when planning strategies to reduce the gastrointestinal damage induced by NSAIDs. Without considering these 3 critical steps, strategies for minimizing the risk of UGI complications in patients treated with NSAIDs will fail. Therefore, doctors should prescribe the appropriate preventive therapy, patients should adhere to that treatment, and eventually doctors need to persistently prescribe the appropriate therapy for patients on chronic long-term treatment with NSAIDs, as is the case for many elderly patients with osteoarthritis or rheumatoid arthritis. The first study reporting some data on these issues came from the Netherlands and showed very low, I would say alarmingly low, rates of prescription of preventive therapies for at-risk patients receiving NSAIDs.4Sturkenboom M.C. Burke T.A. Dieleman J.P. et al.Underutilization of preventive strategies in patients receiving NSAIDs.Rheumatology (Oxford). 2003; 42: 23-31Crossref Google Scholar The authors reported that 86.6% of patients on NSAIDs with 1 risk factor and 81.2% with 2 or more risk factors did not receive prevention strategies for the UGI tract. Since then, several studies have also reported low rates of gastroprotective therapies in NSAID users, ranging from a low 3.8% in Nova Scotia5Hartnell N.R. Flanagan P.S. MacKinnon N.J. et al.Use of gastrointestinal preventive therapy among elderly persons receiving antiarthritic agents in Nova Scotia, Canada.Am J Geriatr Pharmacother. 2004; 2: 171-180Abstract Full Text PDF PubMed Scopus (20) Google Scholar to 27.2% in the United States6Abraham N.S. El-Serag H.B. Johnson M.L. et al.National adherence to evidence-based guidelines for the prescription of nonsteroidal anti-inflammatory drugs.Gastroenterology. 2005; 129: 1171-1178Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar and 60.2% in France.7Thiéfin G. Schwalm M.S. Underutilization of gastroprotective drugs in patients receiving non-steroidal anti-inflammatory drugs.Dig Liver Dis. 2011; 43: 209-214Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, according to more recent studies, these low rates have improved with time, as has been demonstrated in the Netherlands. Correct prescription for high-risk NSAID users rose from 6.9% to 39.4% in 10 years (1996–2006) in one study8Valkhoff V.E. van Soest E.M. Sturkenboom M.C. et al.Time-trends in gastroprotection with nonsteroidal anti-inflammatory drugs (NSAIDs).Aliment Pharmacol Ther. 2010; 31: 1218-1228Crossref PubMed Scopus (41) Google Scholar and from 39.6% to 69.9% in another study (2001–2007).9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar Adherence of patients to the prescribed treatment is another key point. Reported rates of nonadherence broadly range from 9% to 80%, although the most recent studies from Europe reported levels of approximately 70% or higher.9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar, 10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Suboptimal adherence to gastroprotectants (defined as adherence <80% of the prescribed days) has been associated with a 2-fold to 4-fold increase in the risk of UGI bleeding in patients receiving NSAIDs.10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 11Lanas A. Polo-Tomás M. Roncales P. et al.Prescription of and adherence to non-steroidal anti-inflammatory drugs and gastroprotective agents in at-risk gastrointestinal patients.Am J Gastroenterol. 2012; 107 (Erratum in: Am J Gastroenterol 2012;107:639): 707-714Crossref PubMed Scopus (33) Google Scholar In this issue, Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar have formulated a clearer perspective on another aspect of underprescription of gastroprotective agents (PPIs) in NSAID users that has not been described to date. Because many patients take NSAIDs over the long-term, renewal of prescription for gastroprotectants is essential to keep the risk of UGI complications low. Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar conducted a retrospective, observational, longitudinal study by using a validated electronic database covering a representative panel of general practitioners in France. Patients were included if they were at risk for gastrointestinal events and had received an NSAID prescription associated with an initial concomitant PPI prescription. Le Ray et al found that the probabilities of still being prescribed a PPI concomitantly with an NSAID at 1 and 2 years after study inclusion were 77.5% and 68.3%, respectively. Risk factors for nonpersistence were a change in the NSAID molecule, female gender, and absence of gastrointestinal side effects. PPIs were reintroduced in 50% of the cases within 6 months after the patient stopped taking it, without a specific reason being reported in 70% of the cases. The rate of gastrointestinal adverse events was higher in patients lacking an optimal PPI prescription. The authors conclude that physicians omit the renewal of prescriptions for gastroprotective agents in one-third of at-risk patients chronically treated with NSAIDs; this omission is associated with an increased rate of gastrointestinal complications, although this last point (complications) was not actually demonstrated in the study. Far from being bad news for the scientific community and for patients, as could be understood by the authors' conclusion, the findings in this new study represent, in my opinion, a confirmation of the current, increasing tendency for correct implementation of the guidelines recommending gastroprotection in at-risk NSAID/aspirin users, a tendency that has been observed in several European countries.8Valkhoff V.E. van Soest E.M. Sturkenboom M.C. et al.Time-trends in gastroprotection with nonsteroidal anti-inflammatory drugs (NSAIDs).Aliment Pharmacol Ther. 2010; 31: 1218-1228Crossref PubMed Scopus (41) Google Scholar, 9Helsper C.W. Smeets H.M. Numans M.E. et al.Trends and determinants of adequate gastroprotection in patients chronically using NSAIDs.Pharmacoepidemiol Drug Saf. 2009; 18: 800-806Crossref PubMed Scopus (14) Google Scholar, 10Goldstein J.L. Howard K.B. Walton S.M. et al.Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications.Clin Gastroenterol Hepatol. 2006; 4: 1337-1345Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 11Lanas A. Polo-Tomás M. Roncales P. et al.Prescription of and adherence to non-steroidal anti-inflammatory drugs and gastroprotective agents in at-risk gastrointestinal patients.Am J Gastroenterol. 2012; 107 (Erratum in: Am J Gastroenterol 2012;107:639): 707-714Crossref PubMed Scopus (33) Google Scholar, 12van Soest E.M. Sturkenboom M.C. Dieleman J.P. et al.Adherence to gastroprotection and the risk of NSAID-related upper gastrointestinal ulcers and haemorrhage.Aliment Pharmacol Ther. 2007; 26: 265-275Crossref PubMed Scopus (69) Google Scholar Furthermore, the rates of renewal of PPI prescriptions for NSAID users reported by Le Ray et al3Le Ray I. Barkun A.N. Vauzelle-Kervroëdan F. et al.Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury.Clin Gastroenterol Hepatol. 2013; 11: 499-504Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar may represent an underestimation of appropriate prescription therapy to these patients, because a significant proportion of patients (10.4%) who were not prescribed a renewal of a PPI received a cyclooxygenase-2 selective inhibitor instead. On the basis of current guidelines,2Zhang W. Doherty M. Arden N. et al.EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005; 64: 669-681Crossref PubMed Scopus (742) Google Scholar this is a valid and appropriate strategy in at-risk patients. Furthermore, in half of the patients who experienced interruption of the PPI cotherapy, it was reintroduced within 6 months after its cessation, although without a specific reason reported in 70% of the cases. Perhaps the doctors recognized the absence of gastroprotectants with the renewal of the NSAID prescription, or perhaps the patients reported dyspepsia or other symptoms such as gastroesophageal reflux disease. In any case, although the study by Le Ray et al was not specifically designed to evaluate UGI complications, the authors report very few nonserious adverse events (mostly dyspepsia cases and 18 cases of peptic ulcers) in this cohort of patients followed for up to 2 years. These data agree with recent reports showing a dramatic decrease in the number of hospitalizations because of peptic ulcer bleeding and perforation,13Laine L. Yang H. Chang S.C. et al.Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009.Am J Gastroenterol. 2012; 107: 1190-1195Crossref PubMed Scopus (201) Google Scholar even in countries where the prevalence of H pylori infection in elderly people is still high, as are the prescription rates of NSAIDs and PPIs.14Lanas A. García-Rodríguez L.A. Polo-Tomás M. et al.Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice.Am J Gastroenterol. 2009; 104: 1633-1641Crossref PubMed Scopus (389) Google Scholar I believe that taken together, all available data clearly demonstrate that the battle is being won on the side of patient safety, at least in Western countries. The prevalence of H pylori infection is decreasing, and the appropriate prescription of safer NSAID therapy is growing toward optimal levels. At the same time, between one-fourth and one-third of at-risk patients do not receive appropriate preventive NSAID therapy or are not adherent to the prescribed regime; new efforts need to be implemented. Similarly, we need to maintain or even increase the levels of continuing medical education as an essential aspect of our professional career. We must also implement new devices and/or formulas to recall appropriate prescriptions in a world where almost anyone in our profession is electronically “online.” Furthermore, new pill formulations of NSAIDs combined with gastroprotectants are emerging into the market, which will increase the appropriate prescription for and adherence of patients to both NSAIDs and gastroprotective therapy. As often occurs in medicine, new challenges arise when it seems that we are achieving other goals. The battle to prevent UGI complications in NSAID users is moving in the right direction, but a new challenge is now clear. NSAIDs also induce complications from the lower gastrointestinal tract (small bowel and colon). This field retains many open questions, one of the most important of which is identifying appropriate therapies to prevent damage in both the upper and lower gastrointestinal tracts in NSAID users. The implementation of these measures in clinical practice will require new efforts, education, and imagination. Failure to Renew Prescriptions for Gastroprotective Agents to Patients on Continuous Nonsteroidal Anti-inflammatory Drugs Increases Rate of Upper Gastrointestinal InjuryClinical Gastroenterology and HepatologyVol. 11Issue 5PreviewPatients with risk factors for gastrointestinal (GI) disorders who continuously use nonsteroidal anti-inflammatory drugs (NSAIDs) also should take gastroprotective agents (GPAs), such as proton pump inhibitors (PPIs). However, it is not clear how many physicians continue to prescribe GPAs to these patients, and whether stopping the GPA prescription increases GI complications. Full-Text PDF" @default.
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• W2039557632 title "Compliance With Prescriptions of Appropriate Therapy for Nonsteroidal Anti-inflammatory Drug Users: Is the Glass Half Empty or Half Full?" @default.
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