Low-risk arthritis drugs 'could save lives': Better prescribing for elderly patients could prevent 200 deaths a year from bleeding ulcers, study finds

TWO THOUSAND hospital admissions and perhaps 100 to 200 lives a year could be saved if doctors used the least risky of a group of drugs widely prescribed for arthritis and other joint and muscle pains, a large-scale British study has shown.

The finding comes from an investigation of more than 1,100 patients admitted over four years with bleeding peptic ulcers to hospitals in Birmingham, Glasgow, Nottingham, Newcastle upon Tyne and Portsmouth.

The anti-inflammatory pain-killers, known as non-steroidal anti- flammatory drugs (NSAIDs) have long been known to carry some risk of stomach and gut bleeding. But the study found that the risk of ulcer complications in patients aged 60 and over varied more than ten- fold according to which particular drug was being taken.

If doctors prescribed the least risky - ibuprofen - in place of aspirin and the other common NSAIDs, about 2,000 admissions a year could be prevented, the study team led by Michael Langman, Professor of Medicine at Birmingham University, found.

With deaths from bleeding ulcers among over-60s running at between 5 and 10 per cent of admissions, between 100 and 200 lives a year could therefore be saved, Professor Langman said. Hospital admissions could be lowered still further if the drugs were used in low rather than high dose, the study found.

NSAIDs are commonly prescribed for various forms of arthritis, gout and a whole range of less specific joint and muscle pains which afflict older people. Their anti-inflammatory qualities both reduce pain and increase mobility. But the study published in the Lancet shows there are wide variations in the risk they carry of causing bleeding ulcers.

None were risk free, but of the seven most commonly prescribed NSAIDs, ibuprofen followed by diclofenac carried the lowest risk. Indomethicin, naproxen and piroxicam carried intermediate risks. Azapropazone and keoprofen were the highest risk, both being more than 10 times more likely than ibuprofen to be linked to bleeding ulcers.

The individual risk is small - about one in 10,000 prescriptions among people aged 60 and over. But the drugs are very widely used, with more than 20 million prescriptions a year written for them. As a result, they account for between 3,500 and 4,000 hospital admissions annually due to bleeding ulcers, according to the study - a figure which the Lancet, in a leading article, said could be halved if doctors followed the 'few simple guidelines' that emerge from the study by Professor Langman and his colleagues.

'If an NSAID is indicated, the least toxic agent should be given at the lowest effective dose. On this basis, ibuprofen should be the initial choice, at a dose of less than 1,500 milligrams per day.' Meanwhile, the licensing authorities should reconsider the risk-benefit ratio of the other drugs, especially for the elderly, the Lancet said.

The study has again shown up the value of the 'yellow card' system, through which doctors report suspected adverse reactions to drugs. By 1985, the number of yellow cards being sent to the Committee on Safety of Medicines suggested there were wide differences in the risk of stomach bleeding from different NSAIDs. That voluntary reporting system could not quantify the risk, but it raised sufficient questions for the Medical Research Council to back the five-city study which Professor Langman and his colleagues have now reported, showing some NSAIDs are much safer for the gut than others.