Education And Debate

Recent Advances: Rheumatology

BMJ 1995; 310 doi: (Published 11 March 1995) Cite this as: BMJ 1995;310:637
  1. Anthony Bradlow, consultanta,
  2. Joel David, consultanta
  1. a Department of Rheumatology, Battle Hospital, Royal Berkshire and Battle Hospitals NHS Trust, Reading RG3 1AG
  1. Correspondence to: Dr Bradlow.

    The changing philosophies affecting medicine as a whole are at the forefront of rheumatology. Many of the publications of the past year have centred on improving and increasing the safety of drug treatment. There are now good grounds for hope that several newer agents to ameliorate rheumatoid arthritis are available or are in trial phase. Attitudes to chronic back pain and the chronic fatigue syndrome are more positive and treatment is more proactive. Osteoporosis is recognised as an important public health issue; the role of screening with bone densitometry has become better defined.

    Safety of individual non-steroidal anti-inflammatory drugs

    The choice of non-steroidal anti-inflammatory drug for individual patients has until recently depended on the doctor's experience, the class of drug, and the manufacturer's recommendations. A recent publication by the Committee on Safety of Medicines has given a new perspective to selecting them.1 The committee assessed several years of reports of adverse drug reactions (yellow card) for the seven most widely used non-steroidal anti-inflammatory drugs in the United Kingdom. Ibuprofen carried the lowest risk, naproxen, indomethacin, and diclofenac intermediate risk, and azapropazone the highest risk of serious adverse upper gastrointestinal events at the doses in which these drugs are normally prescribed (fig 1). Furthermore, azapropazone had the highest number of yellow card reports for renal, liver, haematological, and hypersensitivity reactions. The report recommends that azapropazone should be used only when other non-steroidal anti-inflammatory drugs have failed, doses being restricted to a maximum of 600 mg daily in patients over 60. Drugs with low risk should generally be preferred, and these should be started in the lowest recommended dose. Only one non-steroidal anti-inflammatory drug should be used at a time. The report concludes that all members of this group are contraindicated in patients with peptic ulceration. This is controversial for patients with rheumatoid arthritis, who frequently have …

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