Reasons Given By Trainees for Avoiding the Use of Acetaminophen and Non-Steroid Anti-Inflammatory Drugs In Patients With Chronic Liver Disease

Abstract

Purpose: A survey by Rossi et al. (Drug Safety 2008;31:261-70) revealed that a majority of primary care physicians would recommend non-steroidal anti-inflammatory drugs (NSAIDs) over acetaminophen (APAP) for patients with chronic liver disease (CLD) while gastroenterologists (GIs) were more likely to recommend APAP at lower doses rather than NSAIDs. However, their study did not address the reasons behind these physicians' recommendations. We are unaware of any information on this topic amongst physicians in training. Therefore, as part of a survey to assess preferences for NSAIDs and APAP in CLD patients by trainees, we inquired about the specific reasons why senior medical students (MS4), internal medicine (IM) residents (PGY1-3), and GI fellows would avoid NSAIDS or APAP in this important patient population. Methods: A 21-question web-based survey was distributed using SurveyMonkey via email to MS4s, residents and GI fellows at several of the major teaching institutions in Washington, DC to determine what recommendations they would make regarding NSAID and APAP use in patients with chronic hepatitis of any cause (group I), compensated cirrhosis (group II), and decompensated cirrhosis (group III). Results: A total of 543 trainees were sent the survey with 174 (32%) responding. The results in Table 1 show that a majority of MS4s and IM residents were concerned about NSAIDs causing ulcers/GI bleeds in patients with CLD, whereas GI fellows were more concerned about NSAIDs precipitating renal failure in these patients. Table 2 shows that a majority of upper level residents and GI fellows were most concerned about APAP worsening underlying CLD as opposed to MS4s and interns. MS4s were the only group to suggest that the perceived lack of evidence-based literature for the safe use of APAP in CLD was their main concern against using APAP.Table 1: Primary reasons for not using NSAIDs in patients with CLDTable: [389] Table 2. Primary reasons for not using APAP in patients with CLDConclusion: The variable responses suggest that more education regarding the adverse effects of NSAIDs in CLD patients is warranted, especially at the student and resident levels. Further studies examining the safety of APAP in CLD are warranted to obtain recommendations that are beyond expert opinion.