The American journal of medicine
-
Nonsteroidal anti-inflammatory drugs (NSAIDs) continue to be used very widely in the community. Their use reflects the significant burden of rheumatic disease on the general population, and they form a basis for the treatment of inflammation in and around the joint. Furthermore, NSAIDs are also being used increasingly for nonrheumatic conditions, including acute and chronic pain, biliary and ureteric colic, and dysmenorrhea. ⋯ NSAIDs play a major role in the management of acute and chronic rheumatic diseases, but their use needs to be tempered with the realization that they can cause potentially serious adverse reactions. These side-effects can be reduced by careful attention to the dose and duration of therapy, concomitant risk factors, and the combined use of more specific drugs to reduce disease activity. Furthermore, the gastrointestinal side-effects of NSAIDs may be treated and prevented by using appropriate therapy in combination with NSAIDs.
-
Nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs in many countries. Use of the majority of NSAIDs increases with age, primarily for symptoms associated with osteoarthritis and other chronic musculoskeletal conditions. Population-based studies have shown that, on any given day, 10-20% of elderly people (> or = 65 years old) have a current or recent NSAID prescription. ⋯ Many studies have now shown that NSAIDs increase the risk of peptic ulcer complications by 3-5-fold, and in several different populations it has been estimated that 15-35% of all peptic ulcer complications are due to NSAIDs. In the United States alone, there are an estimated 41,000 hospitalizations and 3,300 deaths each year among the elderly that are associated with NSAIDs. Factors that increase the risk of serious peptic ulcer disease include older age, history of peptic ulcer disease, gastrointestinal hemorrhage, dyspepsia, and/or previous NSAID intolerance, as well as several measures of poor health.
-
Salicylic acid and salicylates, obtained from natural sources, have long been used as medicaments. Salicylic acid was chemically synthesized in 1860 and was used as an antiseptic, an antipyretic, and an antirheumatic. Almost 40 years later, aspirin was developed as a more palatable form of salicylate. ⋯ It is therefore attractive to suggest that the anti-inflammatory actions of NSAIDs are due to inhibition of COX-2, whereas the unwanted side-effects, such as irritation of the stomach lining, are due to inhibition of COX-1. Drugs that have the highest COX-2 activity and a more favorable COX-2: COX-1 activity ratio will have a potent anti-inflammatory activity with fewer side-effects than drugs with a less favorable COX-2: COX-1 activity ratio. The identification of selective inhibitors of COX-2 will therefore lead to advances in therapy.
-
A 30-50% reduction in fracture risk produced by a drug is biologically "worthwhile." The detection of this benefit, when truly present, is a challenge requiring large studies of 3-5 years' duration, because only a small number of women at risk actually sustain a fracture during this time. For example, in any year, fractures occur in 1-2 per 100 women approximately 65 years of age, 6-10 per 100 women approximately 75 years of age, and only 1-2 per 2,000 of the 15% of women < 60 years of age with osteoporosis. An appreciation of this low annual event rate is important because (1) it helps patients to understand their illness, (2) it determines the power of clinical trials, (3) it underscores the large numbers of patients that must be treated to prevent one fracture, and (4) it underscores the need for safety, particularly in groups at low absolute risk of fracture; all are exposed to drug side effects, and the vast majority derive no benefit from treatment because they would not have had a fracture without it, despite being at risk. ⋯ There have been no studies of the efficacy of any treatment to prevent hip or vertebral fractures in men or in corticosteroid-related osteoporosis. The treatment of osteoporosis is becoming a reality. HRT and the bisphosphonates, particularly alendronate, appear to be the best options at present.
-
The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. ⋯ To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.