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PRIMARY CARE: Lee Hooper, Tamara J Brown, Rachel Elliott, Katherine Payne, Chris Roberts, and Deborah Symmons The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review BMJ 2004; 329: 948 [Abstract] [Full text]

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It's all a matter of doses

Tim Slaughter   (15 October 2004)

Subliminal Message

Peter J Selley   (23 October 2004)

It's all a matter of doses 15 October 2004
Tim Slaughter, Pharmacist Cumberland Infirmary Send response to journal: Re: It's all a matter of doses	I have read the 'online first' copy of the Hooper paper on prevention of non-steroidal GI toxicity. Unfortunately, there are a couple of points that really reduce the validity of the meta-analysis. - the question of doses. For misoprostol, dose-response effects, both good and bad have been shown. Unfortunatley, this article makes no allowance. Similarly, double-dose H2-receptor antagonists have been shown to reduce the risk of duodenal and gastric ulcers, while standard doses have only been shown to reduce the risk of duodenal ulcers. Likewise, much of the information on the COX-II selective agents is based on data on meloxicam. This review (like the NICE review) has fallen into the trap of assessing all strengths together. The low dose (7.5mg) was shown to cause less bleeds but is also less effective than other NSAIDs. By the time you get up to decent therapeutic doses (15mg), any GI advantage is not significant. - a question of duration. This has been well rehearsed before in the pages of the BMJ, but the CLASS data is quoted in its published 6-month form, rather than the now more helpful 12-month form (which is available on the FDA website), which shows no benefit with regards to gastro- intestinalside effects. In the light of the current concerns about the gastrotoxic effects of the NSAIDs, I have found that the CCOHTA reviews (1, 2) far more helpful in attempting to clarify the information. 1. Gastroduodenal ulcers associated with the use of non-steroidal anti-inflammatory drugs: a systematic review of preventive pharmacological interventions (Technology Overview). Available at: http://www.ccohta.ca/publications/pdf/261_gastro_to_e.pdf 2. Gastro-duodenal ulcers associated with the use of non-steroidal anti-inflammatory drugs: a systematic review of preventive pharmacological interventions. Available at: http://www.ccohta.ca/publications/pdf/168_gastroprotective_tr_e.pdf Competing interests: None declared
Subliminal Message 23 October 2004
Peter J Selley, General Practitioner Bow Devon EX17 6EY Send response to journal: Re: Subliminal Message	"COX-2 selectives reduce the risk of symptomatic ulcers; and COX-2 specifics reduce the risk of symptomatic ulcers and possibly serious gastrointestinal complications" No, No, No. They MAY be associated with a smaller risk, compared with other NSAIDs, but they do not reduce the risk of any of these complications. As we pointed out 3 years ago- http://bmj.bmjjournals.com/cgi/eletters/323/7307/251/a -few studies compare newer drugs with the conventional low doses of ibuprofen used in general practice. Indeed "It's all a matter of doses". Competing interests: None declared