Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing * E-mail: pharmacistnuru@gmail.com Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea
Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Formal analysis, Methodology, Supervision, Writing – review & editing Affiliation School of Pharmacy, Asmara College of Health Sciences, Asmara, Eritrea ⨯
Roles Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing Affiliation Department of Statistics, Biostatistics and Epidemiology Unit, College of Science, Eritrean Institute of Technology, Mai Nefhi, Eritrea ⨯
Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing Affiliation Eritrean Pharmacovigilance Center, National Medicines and Food Administration, Asmara, Eritrea
Globally, usage of non-steroidal anti-inflammatory drugs (NSAIDs) in elderly with chronic pain has been reported as frequent. Though NSAIDs are fundamental in maintaining their quality of life, the risk of polypharmacy, drug interactions and adverse effects is of paramount importance as the elderly usually require multiple medications for their co-morbidities. If prescriptions are not appropriately monitored and managed, they are likely to expose patients to serious drug interactions and potentially fatal adverse effects. This study was conducted to assess the appropriateness of NSAIDs use and determine the risk of NSAIDs related potential interactions in elderly. An analytical cross-sectional study was conducted among elderly out-patients (aged 60 and above) who visited three hospitals in Asmara, Eritrea, between August 22 and September 29, 2018. A stratified random sampling design was employed and data was collected using an interview-based questionnaire and by abstracting information from patients’ prescriptions and medical cards. Descriptive and analytical statistics including chi-square test and logistic regression were employed using IBM SPSS (version 22). A total of 285 respondents were enrolled in the study with similar male to female ratio. One in four of all respondents were chronic NSAIDs users and NSAIDs risk practice was reported in 24%. Using chronic NSAIDs without prophylactic gastro-protective agents, self-medication, polypharmacy and drug-drug interactions were the main problems identified. A total of 322 potential interactions in 205 patients were identified and of which, 97.2% were classified as moderate, 0.6% severe and the rest were mild. Those who involved in self-medication were more likely to be exposed to drug interactions. Diabetes (AOR = 2.39, 95% CI: 1.14, 5.02) and hypertension (AOR = 9.06, 95% CI: 4.00, 20.51) were associated with chronic NSAIDs use and incidence of potential drug interactions (AOR = 3.5, 95%CI: 1.68, 4.3; AOR = 2.81, 95%CI: 1.61, 4.9 respectively), while diabetes AOR = 4.5, 95% CI: 2.43, 8.35) and cardiac problems (AOR = 4.29, 95% CI: 1.17, 15.73) were more likely to be associated with incidence of polypharmacy. In conclusion, chronic use of NSAIDs without gastro-protective agents and therapeutic duplication of NSAIDs were commonly which requires attention from programmers, health facility managers and healthcare professionals to safeguard elderlies from preventable harm.
Citation: Abdu N, Mosazghi A, Teweldemedhin S, Asfaha L, Teshale M, Kibreab M, et al. (2020) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Usage and co-prescription with other potentially interacting drugs in elderly: A cross-sectional study. PLoS ONE 15(10): e0238868. https://doi.org/10.1371/journal.pone.0238868
Editor: Jinn-Moon Yang, National Chiao Tung University College of Biological Science and Technology, TAIWAN
Received: March 9, 2020; Accepted: August 25, 2020; Published: October 9, 2020
Copyright: © 2020 Abdu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The complete de-identified data set used for the conclusions of this study is available at: https://osf.io/nm8ue/.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Non-steroidal anti-inflammatory drugs (NSAIDs) are used all over the world for their analgesic, anti-inflammatory, and antipyretic effects [1]. NSAIDs are among the most commonly prescribed class of medications globally and they account for approximately 5–10% of all medications prescribed each year [2]. For obvious reasons, elderly are among the frequent users of NSAIDs [3–5] and the fact that these sub-population are highly involved in prescription and non-prescription medications [6], they are highly susceptible to polypharmacy, drug-drug interactions and ultimately drug related complications and even death [7–9]. Serious/fatal gastrointestinal problems including ulcer and bleeding have been frequently reported with chronic use of NSAIDs [10] and thus, co-prescription of gastro-protective agents has paramount importance in preventing such risks [11]. In the elderly, it was estimated that 29% of fatal peptic ulcer complications were possibly due to NSAIDs [12]. Despite this fact, gastro-protective agents were poorly co-prescribed along with NSAIDs [13] and the other serious adverse effects reported with NSAIDs even amplify this concern.
Use of multiple drugs per prescription (polypharmacy) is recognized as independent risk factor for serious adverse drug reactions in the elderly [14, 15]. On the other hand, the clinician’s perception of the clinical relevance of drug-drug interactions is not fully appreciated [16, 17]; thus, underestimating the relevant risk when multiple drugs are co-administered. Though polypharmacy might be inevitable in these group of populations, clinicians need to follow recent guidelines and continually update their knowledge on potential interactions, safety signals and their risk mitigation strategies.
In clinical practice, there is an important gap between what is theoretically known and practical exercises in the ground [7]. In Eritrea, to the authors knowledge, there no studies conducted so far to evaluate the appropriateness of the use of NSAIDs in elderlies. Due to shortage of physicians, lower health cadres are authorized to prescribe medicines and recent studies show that self-medication and dispensing non-over-the-counter medicines without prescription is a common practice [18, 19].
All the aforementioned factors contributed to the requirement of further research and stricter control on the use of NSAIDs in elderly. This study is therefore conducted to assess the appropriateness of NSAIDs usage and determine the risk of potential drug interactions with NSAIDs in elderlies in selected hospitals in Asmara, Eritrea.
An analytical cross-sectional study with a quantitative approach was conducted in three selected hospitals Asmara, the capital, namely: Halibet national referral hospital, Sembel hospital (private) and Bet-Mekae community hospital. Data was collected between August 22 and September 29, 2018 for a period of 30 working days.
Elderly patients, aged 60 years and above, taking one or more NSAIDs who attended the study sites during the study period formed the study population. Elderly patients, regardless of their sex, who were clinically stable and willing to provide consent to be part of the study were eligible. Subjects with illegibly written prescriptions, those unwilling to participate or with obvious debilitating conditions and who couldn’t pass on reliable information were excluded. The study has no specific source population as one of the selected hospitals was a national referral hospital which follows patients referred or self-referred from other regions.
In order to get representative samples from each hospital, stratified random sampling was utilized. The three hospitals were considered as strata, and participants were selected using systematic random sampling because of the unavailability of prior information on patient visits.
Sample size was computed by considering the finite population correction factor: n = NZ 2 pq/ [pqZ 2 + (N-1)d 2 ]. The total sample size (n) was calculated using the following assumptions: expected proportion of elderly patients with drug interaction (p) and those without drug interaction (q) were taken as 0.5, Z statistic for 95% level of confidence (Z = 1.96), estimated population size (N) of 900, margin of error (d) of 0.05 and 10% non-response rate. Considering the above assumptions, the final sample size was found to be 297.
A data collection form (S1 File) comprising of five sections was used. The data collection form was self-developed and further reviewed using panel of experts in the fields of pharmacy, pharmacoepidemiology and medicine. The interviewers were fifth-year pharmacy students trained in a one-day workshop to ensure perspicuity of the items so as to maximize the within and between inter-rater consistencies. Section A, includes socio-demographic and background characteristics of the patients’ such as age, sex, marital status, educational level, religion, ethnic group, chronic illness and history of gastrointestinal upset. Section B, encompasses, five questions that assess usage of gastro-protective agents among the chronic NSAID users and adverse drug reactions encountered. Section C intends to record information of the prescribed NSAIDs from patients’ prescriptions. This information includes dose, frequency, duration of treatment, route of administration and dosage form. Section D was aimed at recording name of the prescribed and self-medicated drugs for analysis of drug-drug interactions and section E was used to record information from patients’ medical cards like indication(s) of the prescribed NSAID(s), disease status, history of co-morbidities and history of gastrointestinal upset of the patients’. Potential drug interaction was evaluated using drugs.com [20] and WebMD [21] on October 2018.