Goldstein J L, Larson L R, Yamashita B D
Department of Medicine, University of Illinois at Chicago, USA.
Am J Manag Care. 1998 May;4(5):687-97.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage arthritis. While controlling symptoms and improving quality of life, NSAID use is associated with gastroduodenal injury and a 2%-4% annual risk for symptomatic gastroduodenal ulceration, hemorrhage, and perforation. This requires clinicians to balance the efficacy of NSAIDs against the potential risk of serious gastrointestinal events. Identification and stratification of risk can help guide the optimal approach for arthritis management of individual patients or large populations such as managed care organizations. NSAID-induced gastroenteropathy carries considerable economic consequences; 46% of arthritis costs are related to managing serious adverse events. It is reasonable to assume that these costs may not be incurred if high-risk patients are recognized and optimally managed. Newer therapies with proven safety margins present an attractive option, especially for patients at higher risk. The single-tablet formulations of diclofenac and misoprostol (Arthrotec) offer an alternative in managing NSAID patients because of their inherent safety profile. Studies with diclofenac/misoprostol indicate its effectiveness in treating signs and symptoms of arthritis and in reducing the incidence of NSAID-induced gastroenteropathy. As such, this agent may provide improved medical and economic outcomes. This review discusses the clinical aspects of NSAID-induced gastroenteropathy, including available preventive therapies. Approaches to assessing patients' risk for developing complications, and the relationship of medical risk and economic outcomes, are also examined. Although not all patients require preventive therapy, patients with heightened risk may benefit clinically and economically from gastroprotective NSAIDs. Additional research or modeling may provide further insight into the economic implications of managing and preventing NSAID-induced gastroenteropathy.
非甾体抗炎药（NSAIDs）常用于治疗关节炎。在控制症状和改善生活质量的同时，使用NSAIDs与胃十二指肠损伤以及每年2%-4%的有症状胃十二指肠溃疡、出血和穿孔风险相关。这就要求临床医生在NSAIDs的疗效与严重胃肠道事件的潜在风险之间取得平衡。风险的识别和分层有助于指导对个体患者或大型人群（如管理式医疗组织）进行关节炎管理的最佳方法。NSAIDs引起的胃肠病会带来相当大的经济后果；46%的关节炎治疗费用与处理严重不良事件有关。可以合理推测，如果识别出高危患者并进行优化管理，这些费用可能不会产生。具有已证实安全边际的新型疗法是一个有吸引力的选择，特别是对于高危患者。双氯芬酸和米索前列醇的单片制剂（Arthrotec）因其固有的安全性，为管理NSAIDs患者提供了一种替代方案。双氯芬酸/米索前列醇的研究表明其在治疗关节炎的体征和症状以及降低NSAIDs引起的胃肠病发病率方面有效。因此，这种药物可能会改善医疗和经济结果。这篇综述讨论了NSAIDs引起的胃肠病的临床方面问题，包括现有的预防疗法。还研究了评估患者发生并发症风险的方法，以及医疗风险与经济结果之间的关系。虽然并非所有患者都需要预防治疗，但高危患者可能会从具有胃保护作用的NSAIDs中在临床和经济方面获益。进一步的研究或建模可能会更深入地了解管理和预防NSAIDs引起的胃肠病的经济影响。
