ARTHRITIS & RHEUMATISM Vol. 46, No. 8, August 2002, pp 2195–2200 DOI 10.1002/art.10425 © 2002, American College of Rheumatology Underutilization of Gastroprotective Measures in Patients Receiving Nonsteroidal Antiinflammatory Drugs Walter Smalley, C. Michael Stein, Patrick G. Arbogast, Glenn Eisen, Wayne A. Ray, and Marie Griffin Objective. To determine the frequency of use of recommended gastroprotective strategies in a cohort of patients receiving recurrent treatment with nonsteroi- dal antiinflammatory drugs (NSAIDs). Methods. A cross-sectional study was performed using administrative data from the Tennessee Medicaid (TennCare) program. The study population consisted of 76,765 recurrent recipients of NSAIDs (NSAID users), comprising 24% of the 319,402 persons ages 50 years or older enrolled in the TennCare program from January 1999 through June 2000. Frequency of use of either of 2 recommended gastroprotective strategies, involving ei- ther traditional NSAIDs combined with recommended anti-ulcer cotherapy or use of a selective cyclooxygenase 2–inhibiting drug (coxib), was measured and catego- rized by risk for ulcer complication. Results. Among this cohort of recurrent NSAID users, 16% received 1 of the 2 recommended gastropro- tective therapies: 10% received traditional NSAIDs along with antiulcer drugs at the recommended doses and 6% received coxibs. Among those patients with >2 risk factors for ulcer complications (age 75 years or older, peptic ulcer or gastrointestinal bleeding in the past year, or concurrent use of oral anticoagulants or corticosteroids), 30% received such gastroprotective therapy. Conclusion. Use of recommended strategies to decrease ulcer complications in vulnerable populations is relatively uncommon. Nonsteroidal antiinflammatory drugs (NSAIDs) are currently among the most commonly prescribed pharmaceuticals, with 111 million prescriptions for NSAIDs in the United States in 2000 (1). The cycloox- ygenase 2 selective inhibitors (coxibs), celecoxib and rofecoxib, are newer NSAIDs that became available in late 1998 and early 1999 (2,3) and whose use has increased rapidly, due, in part, to their greater gastroin- testinal safety as compared with traditional NSAIDs. Approximately 1–2% of older patients taking traditional NSAIDs regularly for 1 year develop serious gastrointestinal complications such as perforation, ob- struction, or bleeding (4–6). An additional 2–3% de- velop other clinically important adverse gastrointestinal events such as uncomplicated ulcers (5). More than 70,000 hospitalizations and 10,000–20,000 deaths per year in the US have been attributed to NSAIDs (7). Important risk factors for NSAID-associated complica- tions include older age, a history of peptic ulcer or gastrointestinal bleeding, concomitant use of anticoagu- lants or corticosteroids, and higher doses of NSAIDs (2,3,5,6,8). There are several strategies that have been developed, supported by evidence of varying strength, to decrease the risk of NSAID-associated adverse gastro- intestinal events. These include discontinuing all NSAIDs, prescribing a coxib rather than a traditional NSAID, or prescribing a traditional NSAID with gastro- protective cotherapy such as misoprostol, proton pump inhibitors (PPIs), or high-dose histamine-2 receptor antagonists (H2RAs) (9–11). The Misoprostol Ulcer Complications Outcome Dr. Smalley serves as a safety consultant for Novartis, a company that is in the process of developing a selective cyclooxygenase 2 (COX-2) inhibitor. Dr. Eisen serves as a consultant to Pharmacia, a company that markets the COX-2 selective drug celecoxib. Dr. Griffin serves as a consultant to Merck, a company that markets the COX-2 selective drug rofecoxib. Supported in part by the Center for Education and Research on Therapeutics (AHRQ U18-HS10384) and the Geriatrics Research, Education and Clinical Center of the Veterans Administration Ten- nessee Valley Healthcare System. Walter Smalley, MD, MPH, C. Michael Stein, MD, Patrick G. Arbogast, PhD, Glenn Eisen, MD, MPH, Wayne A. Ray, PhD, Marie Griffin, MD, MPH: Vanderbilt University, Nashville, Tennessee. Address correspondence to Walter Smalley, MD, MPH, C- 2104 MCN, 21st and Garland, Nashville, TN 37232. E-mail: walter.smalley@mcmail.vanderbilt.edu. Address reprint requests to Marie Griffin, MD, MPH, A-1110 MCN, 21st and Garland, Nashville, TN 37232. Submitted for publication October 24, 2001; accepted in revised form April 4, 2002. 2195