Nonsteroidal Anti-inflammatory Drugs Prophylaxis Research Articles

Classification and Incidence of Heterotopic Ossifications in Relation to NSAID Prophylaxis after Elbow Trauma

Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study’s primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6–85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ2) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen’s Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury’s location and the HO’s location after 12 weeks (p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.

Outcomes comparison between nsaid and placebo in the occurrence of heterotopic ossification after hip surgery: a systematic review

Introduction: Heterotropic Ossification (HO) is a devastating condition felt by patients and surgeons. It was caused by inflammatory response triggered by injury through various processes. NSAID is thought to have a capability to limit the process, hence preventing the condition.
 Materials and Methods: Various database has been used to search for literatures included in this review. Screening and evaluation were conducted for researches.
 Results: Seven studies are included in this review and a table has been formed to show the comparison of HO and Control.
 Discussion : This study aimed to assess the occurrence of heterotopic ossification (HO) after hip arthroscopy and compare outcomes between those who received prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) and those who did not. The hypothesis was that NSAIDs could reduce postoperative HO. The significance of this trend varied in retrospective research due to differences in NSAID regimens. The usefulness of NSAID prophylaxis should be carefully weighed against potential side effects, and patient compliance should be assessed in future research, as it was inconsistently reported in the existing literature.
 Conclusion: NSAID lower the rate of postoperative HO, however, more studies need to be conducted to analyze certain efficacy of certain type of HO

Safety of colchicine and NSAID prophylaxis when initiating urate-lowering therapy for gout: propensity score-matched cohort studies in the UK Clinical Practice Research Datalink

ObjectivesTo determine the risk of adverse events associated with colchicine or non-steroidal anti-inflammatory drug (NSAID) prophylaxis when initiating allopurinol for gout.MethodsWe conducted two matched retrospective cohort studies in linked UK...

P145 Safety of colchicine or NSAID prophylaxis when initiating allopurinol for gout: propensity score-matched cohort studies

Abstract Background/Aims Initiating urate-lowering therapy for gout commonly triggers a gout flare and hence co-prescription of colchicine or non-steroidal anti-inflammatory drug (NSAID) prophylaxis is recommended. However, little is known about the incidence of adverse events associated with prophylaxis. We aimed to determine the risk of adverse events severe enough to warrant seeking healthcare associated with colchicine or NSAID prophylaxis when initiating allopurinol for gout. Methods We conducted two matched retrospective cohort studies, using linked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) datasets. Adults aged ≥18 years with a Read code for gout and a new allopurinol prescription between 1997 and 2016 were identified. We compared those prescribed (1) colchicine or (2) NSAID prophylaxis with those prescribed no prophylaxis, individually matched by age, sex and propensity to receive prophylaxis, to reduce the impact of confounding by indication. Adverse events were identified in CPRD and HES using Read and ICD10 codes respectively. Associations between colchicine or NSAID prophylaxis and the first occurrence of each outcome were investigated using weighted Cox proportional hazards models. CPRD Gold and Aurum datasets were analysed separately and then combined using 2-stage individual patient data meta-analysis. Results 13,945 individuals who initiated allopurinol with colchicine prophylaxis were matched to 13,945 who initiated without prophylaxis (mean age 63.62 years [95%CI 63.54, 63.70]; 78% male). Diarrhoea was the most common adverse event in the colchicine group, followed by nausea/vomiting, myocardial infarction (MI), neuropathy, myalgia, and bone marrow suppression (Table). Diarrhoea, MI, neuropathy, myalgia, and bone marrow suppression were significantly more common with colchicine prophylaxis compared with no prophylaxis. 22,880 individuals who initiated allopurinol with NSAID prophylaxis were matched to 22,880 who initiated without prophylaxis (mean age 63.34 years [95%CI 63.26, 63.42]; 78% male). Angina, acute kidney injury, MI, and peptic ulcer disease were significantly more common with NSAID prophylaxis than without (Table). Conclusion Gastrointestinal, cardiorenal, myoneuropathic, and haematological adverse events were associated with prophylaxis, although absolute event rates were low. This information can inform treatment decisions and choice of colchicine or NSAID for prophylaxis when initiating allopurinol. Disclosure E. Roddy: None. R. Bajpai: None. H. Forrester: None. R. Partington: None. C.D. Mallen: Grants/research support; Keele University School Of Medicine has received funding from BMS to support a non-pharmacological atrial fibrillation screening study. L. Clarson: None. N. Padmanabhan: None. R. Whittle: None. S. Muller: None.

Optimal timing of rectal diclofenac in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis.

Background and study aims Rectal nonsteroidal anti-inflammatory drug (NSAID) prophylaxis reduces incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparisons to the optimal timing of administration, before or after ERCP, are lacking. Therefore, we aimed to assess whether timing of rectal NSAID prophylaxis affects the incidence of post-ERCP pancreatitis. Patients and methods We conducted an analysis of prospectively collected data from a randomized clinical trial. We included patients with a moderate to high risk of developing post-ERCP pancreatitis, all of whom received rectal diclofenac monotherapy 100-mg prophylaxis. Administration was within 30 minutes before or after the ERCP at the discretion of the endoscopist. The primary endpoint was post-ERCP pancreatitis. Secondary endpoints included severity of pancreatitis, length of hospitalization, and Intensive Care Unit (ICU) admittance. Results We included 346 patients who received the rectal NSAID before ERCP and 63 patients who received it after ERCP. No differences in baseline characteristics were observed. Post-ERCP pancreatitis incidence was lower in the group that received pre-procedure rectal NSAIDs (8 %), compared to post-procedure (18 %) (relative risk: 2.32; 95% confidence interval: 1.21 to 4.46, P = 0.02). Hospital stays were significantly longer with post-procedure prophylaxis (1 day; interquartile range [IQR] 1–2 days vs. 1 day; IQR 1–4 days; P = 0.02). Patients from the post-procedure group were more likely to be admitted to the ICU (1 patient [0.3 %] vs. 4 patients [6 %]; P = 0.002). Conclusions Pre-procedure administration of rectal diclofenac is associated with a significant reduction in post-ERCP pancreatitis incidence compared to post-procedure use.

Heterotopic Ossification Prophylaxis Following Operative Fixation of Acetabular Fractures: A Systematic Review.

Heterotopic ossification (HO) is a well-recognized complication following operative fixation of acetabular fractures with a range of severity and clinical consequences. The purpose of this review was to: (1) report the incidence of heterotopic ossification (HO) formation following operative fixation of acetabular fractures; (2) determine the effectiveness of prophylactic treatments for HO; and (3) assess the radiographic severity of HO with and without prophylactic treatment. A literature search for peer-reviewed articles was conducted utilizing a variety of research databases. PRISMA guidelines were followed and included in this review were full-length, English language manuscripts published before September 2019, using the following search criteria: "heterotopic ossification AND acetabulum OR acetabular." Studies that reported HO as one of the reported outcomes were included. Articles were excluded if radiographic HO was not reported and if it was evaluated in surgeries other than those involved in acetabular fractures. Extracted data included, but was not limited to: type of prophylaxis; incidence of HO; severity of HO based on the Brooker classification; and statistical significance. A methodologic quality appraisal of the included studies was also conducted. A total of 54 full-text studies with 5,890 patients with operatively fixed acetabular fractures met inclusion criteria. There were four level I studies, four level II study, 26 level III studies, and 20 level IV studies. The overall incidence of HO after acetabular fracture surgery was 28.4%. The rate of HO formation was: 34.9% without prophylaxis, 28.3% with non-steroidal anti-inflammatory drugs (NSAID) prophylaxis, and 21.2% with radiation therapy (RT). Patients receiving a combination of both RT and NSAIDs developed HO 21.8% of the time. The rate of radiographic severe HO was 13.9% (range, 0-75%) in patients without prophylaxis, 9.4% (range, 0-50%) with NSAID prophylaxis, 5.7% (range, 0-12.8%) with RT prophylaxis, and 11.7% (range, 0-18.5%) with the combination of RT and NSAIDs. With the current literature collected in this systematic review, there was a lower incidence and severity of heterotopic bone formation following acetabular fracture fixation using radiation prophylaxis compared to NSAIDs or no treatment. The available literature is heterogeneous in fracture characteristics, surgical approaches, and prophylactic regimens with a general lack of randomized control trials. Further prospective studies are required to make definitive claims on the optimal prophylactic strategy to prevent heterotopic ossification.

Heterotopic Ossification After Arthroscopic Procedures: A Scoping Review of the Literature.

Background:Heterotopic ossification (HO) is the formation of bone in soft tissue resultant from inflammatory processes. Lesion formation after arthroscopic procedures is an uncommon but challenging complication. Optimal prophylaxis and management strategies have not been clearly defined.Purpose:To present a scoping review of the pathophysiology, risk factors, diagnostic modalities, prophylaxis recommendations, and current treatment practices concerning HO after arthroscopic management of orthopaedic injuries.Study Design:Scoping review; Level of evidence, 4.Methods:A scoping review via a PubMed search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The search strategy was based on the terms “heterotopic ossification” AND “arthroscopy.” The clinical outcomes review included studies on the arthroscopic management of orthopaedic injuries in which the primary subject matter or a secondary outcome was the development of HO. An analysis of the pathophysiology, diagnostic modalities, and management options was reported.Results:A total of 43 studies (33,065 patients) reported on HO after hip arthroscopy, while 21 (83 patients) collectively reported on HO after arthroscopic procedures to the shoulder, elbow, knee, or ankle; however, management techniques were not standardized. Identified risk factors for HO included male sex and mixed impingement pathology, while intraoperative capsular management was not suggested as a contributing factor. Diagnosis of ossification foci was performed using radiography and computed tomography. The rate of HO after hip arthroscopy procedures approached 46% without prophylaxis, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased occurrence rates to 4% but carries associated risks. External beam radiation has not been exclusively studied for use after arthroscopic procedures.Conclusion:HO is a known complication after arthroscopic management of orthopaedic injuries. NSAID prophylaxis has been demonstrated to be effective after hip arthroscopy procedures. Patients with persistent symptoms and mature lesions may be indicated for surgical excision, although variability is present in patient-reported outcome scores postoperatively.

Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery

PurposeWe evaluate the incidence of heterotopic ossification (HO) development with nonsteroidal anti-inflammatory drug (NSAID) prophylaxis in patients after open and arthroscopic hip preservation surgery.MethodsA retrospective review identified patients who underwent hip preservation surgery at a single institution within the past 3 years. Patients who underwent hip arthroscopy with or without periacetabular osteotomy (PAO) or femoral osteotomy (FO) were included. Those who did not receive 3-month postoperative radiographs were excluded. The incidence and Brooker classification (BC) of HO in patients taking Naproxen or another NSAID (meloxicam, celecoxib, indomethacin, or aspirin alone) was assessed using AP radiographs available from 3-, 6-, and 12-month follow-up appointments. Univariate analysis was conducted to compare numerical means and categorical data (significance level P = .05).ResultsA total of 328 hips (284 patients) were included. All patients received hip arthroscopy, while 71 patients (21.6%) received concurrent periacetabular osteotomy (PAO; n = 65) or femoral osteotomy (FO; n = 6). Overall, 276 hips (84.4%) received Naproxen for HO prophylaxis. In total, 5 of 328 hips (1.5%) developed HO (4, BC I; 1, BC III). The rate of HO development was significantly higher in males versus females (4 of 121 (3.31%) vs 1 of 207 (.48%), P = .0441). All 5 patients received arthroscopic cam resection and labral repair, and 1 patient also received PAO. Three patients in the Naproxen group (.91%) developed HO, which was not statistically different from those taking a different NSAID (.61%, P = .1797).ConclusionThe incidence of HO development was low with NSAID prophylaxis after hip preservation surgery.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury.Materials and Methods We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis.Results Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up.Conclusion There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference.Level of Evidence Level III.

Use of nonsteroidal anti-inflammatory drugs to prevent heterotopic ossification after spinal cord injury: a retrospective chart review.

Retrospective chart review. The objective of this study is to evaluate the efficacy of nonsteroidal anti-inflammatory drug (NSAID) prophylaxis for heterotopic ossification (HO) in the acute phase after spinal cord injury (SCI). Acute rehabilitation hospital in California, USA. This retrospective chart review (October 2013-March 2017) included individuals with motor complete SCI followed by the SCI service within 60 days of injury. Group demographics and HO diagnosis were compared in those who received and those who did not receive NSAID prophylaxis. A backward stepwise multiple regression was employed to assess the predictive association between injury characteristics and HO prophylaxis on HO diagnosis. A total of 108 AIS A and B cases were included, and 27 received ≥ 15 days of therapy (overall range 6-44 days). Logistic regression analysis revealed those who received ≥ 15 days of NSAID prophylaxis had an odds ratio of 0.1 of being diagnosed with HO compared with those who did not (95% CI, 0.02 to 0.52). Significant predictors of HO diagnosis were tracheostomy (OR 2.8, 95% CI, 1.05 to 7.5), urinary tract infection (OR 4.3, 95% CI, 1.5 to 12.2), and pressure injury (OR 3.3, 95% CI, 1.1 to 9.5). Adverse effects of NSAID use were minimal. NSAID prophylaxis appears to help prevent HO development during the acute phase after SCI. Prospective study with prolonged follow up is necessary to confirm the long-term efficacy of HO prevention and to further evaluate safety following spinal fusion. None.

Nonsteroidal Anti-inflammatory Drugs for Endoscopic Retrograde Cholangiopancreatography Postoperative Pancreatitis Prevention: a Systematic Review and Meta-analysis

Background or PurposeThere is controversy regarding the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) for prophylaxis against endoscopic retrograde cholangiopancreatography (ERCP) postoperative pancreatitis. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy of NSAIDs for prophylaxis against post-ERCP pancreatitis (PEP). MethodsPubMed, EMBASE, and Cochrane library databases were searched for relevant randomized controlled trials (RCTs). Selected RCTs were pooled under a fixed effects model to generate the relative risks (RRs) and their corresponding 95% confidence intervals (CIs). ResultsNineteen RCTs involving a total of 5031 patients (2555 in the intervention group and 2476 in the control group) were selected. Overall, NSAIDs were associated with a significant reduction in risk of PEP (RR = 0.54, 95% CI 0.45 to 0.64, I2 = 40.4%) and moderate to severe PEP (RR = 0.45, 95% CI 0.30 to 0.67, I2 = 0%) compared with the control group. Subgroup analyses were performed according to route of administration (rectal or other), type of NSAIDs (diclofenac, indomethacin, or other), timing of administration (pre-ERCP, post-ERCP, or other), and patient population (high risk or general). Subgroup analyses showed difference in clinical efficacy of NSAID prophylaxis regardless of route, timing, or specific type of NSAID. ConclusionNSAIDs were associated with a significant reduction in risk of PEP and moderate to severe PEP compared to the control group.

Selective COX-2 Inhibitors Significantly Reduce the Occurrence of Heterotopic Ossification After Hip Arthroscopic Surgery

Background: Heterotopic ossification (HO) after hip arthroscopic surgery is a common complication and may be associated with clinical sequelae such as pain, impingement, and decreased range of motion. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used medications for reducing or preventing HO. Hypothesis/Purpose: The purpose of this study was to evaluate the effectiveness of short-term selective cyclooxygenase-2 (COX-2) inhibitors used for HO prophylaxis after hip arthroscopic surgery. The hypothesis was that postoperative HO prophylaxis with 600 mg etodolac once daily for 2 weeks would significantly reduce the incidence of HO after hip arthroscopic surgery when compared with no prophylaxis. Study Design: Cohort study; Level of evidence, 3. Methods: Between July 2010 and April 2014, a total of 263 consecutive patients underwent hip arthroscopic surgery, performed by a single surgeon, for various pathological abnormalities at 1 medical center. The initial 163 patients received no postoperative NSAID prophylaxis for HO, and the subsequent 100 patients received 600 mg etodolac once daily for 2 weeks postoperatively. Prophylaxis compliance data, gastrointestinal side effects, and postoperative radiographs for HO were monitored. Results: A total of 100 control patients and 63 study patients met the inclusion criteria. The mean follow-up period was 12.88 months. No significant differences were observed in terms of age, sex, follow-up, or procedures performed. No gastrointestinal bleeding was observed. Radiographic findings of HO were present in 36 of 100 control patients with 17, 15, and 4 classified as having Brooker grades 1, 2, and 3, respectively. No patients in the study group presented with HO, and a significant difference in the HO rate between groups was observed (P < .0001). Conclusion: HO after hip arthroscopic surgery is a relatively common complication, with a rate of 19% for Brooker grade ≥2 in the patients who did not receive NSAID prophylaxis. No HO was found in the patients who received short-term COX-2 inhibitor prophylaxis. The short-term administration of 600 mg etodolac once daily for 2 weeks was found to be safe and effective in preventing HO in patients undergoing hip arthroscopic surgery. HO prophylaxis protocols based on short-term etodolac treatment may be considered after hip arthroscopic surgery.

Hip Arthroscopy and Heterotopic Ossification: Is NSAID Prophylaxis Justified? Commentary on an article by James T. Beckmann, MD, MS, et al.: "Effect of Naproxen Prophylaxis on Heterotopic Ossification Following Hip Arthroscopy: A Double-Blind Randomized Placebo-Controlled Trial".

Heterotopic ossification (HO) is a process in which unwanted and potentially disabling bone tissue forms in abnormal locations such as muscles, musculotendinous junctions, and joint capsules. It may occur after trauma and after surgery. It is well known around the elbow and hip following fracture surgery and total hip replacement. The number of hip arthroscopies performed has increased exponentially over the last decade, and HO has become well recognized following this mini-invasive procedure. Although not as commonly experienced as a clinical problem, it is frequently demonstrated on postoperative radiographs. It is therefore of interest to investigate whether this abnormal bone formation can be reduced in a controlled study. Nonsteroidal antiinflammatory drugs (NSAIDs) have been used to prevent HO for years in other settings and are also commonly used following hip arthroscopy. However, NSAIDs may also cause serious complications, and knowledge about the effect and risk in each specific indication is important. The article by Beckmann et al. addressed this problem in a well-conducted double-blind randomized controlled trial (RCT) in which three weeks of treatment with 500 mg of naproxen twice daily was compared with a placebo. They found a remarkable difference between the NSAID group and the placebo group with regard to radiographic findings of HO (documented in 4% and 46% of the patients, respectively). Medication compliance was 69% overall, and minor adverse events were reported in 42% in the treatment group and 35% in the control group. Only one patient developed symptomatic HO that required revision surgery. Unfortunately, few RCTs have been performed in orthopaedics, including the quickly evolving field of hip arthroscopy. New techniques have been developed and implemented without full knowledge of the benefit for the patients and how to select the right treatment for the right patient. In a PubMed search for “hip arthroscopy,” 801 studies were found, but when the search was limited to RCTs there were eight (and all were not actually RCTs). However, there is promising research under way: RCTs on the general efficacy of hip arthroscopy are ongoing. The study by Beckmann et al. is an important and welcomed contribution to this so far limited number of Level-I hip arthroscopy studies. NSAIDsmay affect tissue healing. Healing of soft tissue (such as a tendon) to bone has been shown to be impaired byNSAIDs in experimental studies. A negative effect of NSAIDs on the healing of the sutured labrum or capsule in hip arthroscopy may therefore be an issue. NSAIDs have potential serious side effects, and although Beckmann et al. did not report serious or fatal complications in their study of 108 patients, they may occur sooner or later in a larger patient population. Clinically relevant HO is uncommon, and this has to be weighed against the risk of serious side effects caused by NSAIDs. Another question is whether the HO is a temporary phenomenon. A follow-up study of this patient cohort would be of great interest to see to what extent the HO develops further, is reduced, or disappears. This well-performed double-blind RCT documents that NSAIDs can reduce the frequency of radiographic evidence of HO following hip arthroscopy to a minimum. However, the clinical benefit and potential harm of routine NSAID prophylaxis are still unknown. As the authors point out, the lowest dose and shortest duration of NSAID prophylaxis that still prevent HO remain to be determined. This important study raises new questions, and there are many possible directions for further research in this field. Sverre Loken, MD, PhD* Oslo University Hospital, Oslo, Norway

Dosage effects of histamine-2 receptor antagonist on the primary prophylaxis of non-steroidal anti-inflammatory drug (NSAID)-associated peptic ulcers: a retrospective cohort study.

A histamine-2 receptor antagonist (H2RA) is one of the common gastroprotective co-therapies used with non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention or treatment of peptic ulcers (PUs). To date, no study has directly compared the prophylactic effectiveness between high-dose and low-dose H2RA. Our objective was to compare the effectiveness of high-dose versus low-dose H2RAs in the primary prophylaxis of PUs among short-term NSAID users. A retrospective cohort study was conducted using the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong. Patients aged 18years or above who received a single prescription of oral NSAID with oral H2RA were identified within the study period (1 January 2009-31 December 2012). Patients with a history of or risk factors for PU in the corresponding 2 years prior to the index date (of the first NSAID prescription) were excluded. Log binomial regression analysis was used to calculate the relative risk of PU among NSAID users with high-dose H2RA versus low-dose H2RA exposure. Among the NSAID cohort (n = 102,042), 77,509 (76%) were on low-dose H2RA and 24,533 (24%) were on high-dose H2RA. Of the total 69 PU cases identified during the drug exposure period, 64 (0.08%) received low-dose-H2RA and five (0.02%) received high-dose H2RA. The overall absolute risk of PUs for NSAID users whilst on H2RA was approximately 1 per 1,479 patients. The adjusted relative risk for NSAID users receiving high-dose H2RA versus low-dose H2RA was 0.32 (95% confidence interval [CI] 0.13-0.79). Patients aged ≥65years, receiving a longer duration of treatment, or with concomitant use of antiplatelet agents were found to be at higher risk of PU. High-dose H2RA showed greater effectiveness than low-dose H2RA in the primary prophylaxis of NSAID-associated PUs in short-term new users.

The Effect of NSAID Prophylaxis and Operative Variables on Heterotopic Ossification After Hip Arthroscopy

Background: Heterotopic ossification (HO) is a known complication of hip arthroscopy. Little is known about the factors that lead to HO after hip arthroscopy. Purpose: The aim of this study was to evaluate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) and other operative variables on the development of HO. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 357 consecutive cases of hip arthroscopy were retrospectively reviewed over a 3-year period. Routine NSAID prophylaxis was not performed for the first 117 cases. Prophylaxis with naproxen for 3 weeks was then routinely prescribed for the remaining 240 cases. Complete follow-up was available for 288 of the original 357 cases. The presence of HO and its characteristics were recorded for each patient, along with baseline demographic and surgical variables. Odds ratios and logistic regression were used to identify causal factors for HO. Results: The incidence of HO in cases in which the patient did not receive NSAID prophylaxis was 25.0% (23/92) versus 5.6% (11/196) of cases in which the patient received NSAIDs. Patients who received no NSAID prophylaxis were 13.6 times more likely to develop HO postoperatively (95% confidence interval, 2.44-75.5; P = .003). Comparing just mixed-type femoroacetabular impingement resections, patients who received no NSAID prophylaxis were 16.6 times more likely to develop HO postoperatively (95% confidence interval, 2.2-126.0; P = .006). Multivariate logistic regression identified the performance of a mixed-type femoroacetabular impingement resection (P = .011) and the absence of NSAID prophylaxis (P = .003) as predictors of HO development. The majority of HO cases (29/34) occurred in patients with mixed-type femoroacetabular impingement who had both osteochondroplasty and acetabuloplasty. Complications of NSAID therapy in this study population included acute renal failure, hematochezia from acute colitis, and gastritis. Conclusion: Routine NSAID prophylaxis reduces but does not eliminate the incidence of HO in patients undergoing hip arthroscopy. Heterotopic ossification was more likely to develop in patients undergoing acetabuloplasty along with osteochondroplasty and in those who did not receive prophylactic postoperative NSAIDs. Side effects from the investigated NSAID regimen can be serious and should be weighed against the potential benefits in preventing the formation of HO.

A Meta-Analysis on the Role of Rectal Diclofenac and Indomethacin in the Prevention of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Clinical trials evaluating the protective effect of nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) have yielded inconclusive results. Our objective was to conduct a meta-analysis of the data to date to evaluate the efficacy and safety of rectal NSAIDs for PEP prophylaxis. We did a systematic search of PubMed/MEDLINE, Embase, and Web of Science databases and the Cochrane Central Register of Controlled Trials. The meta-analysis was performed using a fixed-effect method because of the absence of significant heterogeneity in the included trials. Seven randomized, controlled trials involving 2133 patients were included. The meta-analysis showed that rectal NSAIDs decreased the overall incidence of PEP (risk ratio, 0.44; 95% confidence interval, 0.34-0.57; P < 0.01). The number needed to treat was 11. The NSAID prophylaxis also decreased the incidence of moderate to severe PEP (risk ratio, 0.37; 95% confidence interval, 0.27-0.63; P < 0.01). The number needed to treat was 34. No differences of the adverse events attributable to NSAIDs were observed. In conclusion, prophylactic use of rectal NSAIDs reduces the incidence and severity of PEP. There is neither a difference in efficacy between rectal indomethacin and diclofenac nor a difference in efficacy between the timing of administration of rectal NSAIDs, that is, immediate pre-ERCP and post-ERCP.

Balancing the Risks and Benefits of Proton Pump Inhibitors

Balancing the Risks and Benefits of Proton Pump Inhibitors

Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis.

BackgroundOpen hip surgery is known to be a risk for heterotopic ossification (HO), and nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely recognized as an effective prevention. Hip arthroscopy is gaining popularity thanks to the possibility of treating femoroacetabular impingement (FAI) with a minimally invasive technique, however little is known about its rate of postoperative HO. The aim of the present study is to evaluate HO prevalence after hip arthroscopy for FAI and its relationship with NSAID prophylaxis.Materials and methodsWe retrospectively reviewed 300 FAI cases who have been managed with hip arthroscopy in two different hospitals from April 2006 to May 2009. All medical records and indications at discharge were analyzed, focusing on administration of NSAIDs, as well as follow-up roentgenograms with regard to presence of HO around the hip joint. The patients were divided into two groups: a treatment group of 285 hips which received NSAID prophylaxis and a control group of 15 hips which did not.ResultsFive hips presented HO, with overall prevalence of 1.6%. All five patients with HO belonged to the control group. No HO was observed in the treatment group. Thus, HO rate turned out to be significantly higher (P < 0.001) in patients who did not receive NSAIDs after surgery.ConclusionArthroscopic treatment of FAI is not exempt from potential development of HO. NSAIDs after arthroscopic FAI treatment seem to be an effective prevention.

Appropriateness of treatment recommendations for PPI in hospital discharge letters.

PurposeThe reasons for the dramatic increase in proton pump inhibitors (PPI) prescriptions remain unclear and cannot be explained solely by increased morbidity, new indications or a decrease in alternative medication. Inappropriate use and discharge recommendations in hospitals are considered to be possible explanations. As the quality of PPI recommendations in hospital discharge letters in Germany has not been investigated to date, we have studied the appropriateness of these referrals.MethodsHospital discharge letters with recommendations for PPI medication from 35 primary care practices in the county of Mecklenburg-Western Pomerania (MV; North-east Germany) were collected and analysed, and the appropriateness of the PPI indication was rated.ResultsNo information justifying the recommendation for continuous PPI medication could be identified in 54.5% of the discharge letters; in 12.7%, the indication was uncertain, and in 32.7%, we found an evidence-based indication for PPI medication. The most common indication for adequate PPI use was nonsteroidal anti-inflammatory drug-prophylaxis in high-risk patients.ConclusionsInadequate recommendations for PPIs in discharge letters are frequent. This may lead to a continuation of this therapy in primary care, thereby unnecessarily increasing polypharmacy and the risk of adverse events as well as burdening the public health budget. Hospitals should therefore critically review recommendations for PPI medication and the dosage thereof in their discharge letters and clearly document the reason for PPI use and the need for continuous prescription in primary care.

The suppression of heterotopic ossifications: Radiation versus NSAID therapy—A prospective study

This prospective, randomized study compares the effect of postoperative irradiation and nonsteroidal anti-inflammatory drug (NSAID) therapy on the prevention of heterotopic ossifications after the implantation of a total hip endoprosthesis. A total of 154 operations were performed; one group of patients underwent radiation treatment of 3 × 3.3 Gy, and the other group took 3 × 50 mg of diclofenac per day over a period of 3 weeks. Average age, sex, preoperative diagnosis, and risk factors were similar in both groups. Postoperative radiation began on average 2.9 days after operation, and the radiation therapy was finished on average within 3.8 days. NSAID prophylaxis was begun on the first postoperative day. Heterotopic ossifications occurred in two of the patients who had undergone postoperative prophylaxis by radiation. In both cases, the ossification was Brooker I, and there was no functional impairment. There were no ossifications of Brooker II–IV in this group. One patient had a Staphylococcus epidermidis infection, and fistula revision had to be carried out; the prosthesis could be left in place. In the group treated with NSAID, 16 heterotopic ossifications stage Brooker I and 2 stage Brooker II could be detected. Eleven patients stopped the treatment because of gastrointestinal problems. Both postoperative radiation and NSAID therapy have proved to be effective prophylactic methods. In direct comparison, radiation prophylaxis by 3 × 3.3 Gy proved to be slightly more successful than NSAID prophylaxis.