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Aronson illustrated that the definition of frequency qualifiers
cannot be taken for granted. (1) However, we often omit them completely as
we condense complex research findings into terse one-liners. This can
dramatically distort our perception of risk.
For example, nobody would disagree that non-steroidals (NSAIDs) are
an important cause of avoidable iatrogenic mortality in the elderly,
largely through ulceration and perforation of the upper gastrointestinal
tract. These ideas profoundly influence our prescribing: we may avoid
their use altogether or co-prescribe prophylactic measures.
Reputable studies suggest that, for NSAID users over the age of 75,
the annual risks for serious GI bleed and death are 1 in 110 and 1 in 650
respectively, and that there is one episode of ulcer bleeding in the
elderly for every 2,823 NSAID prescriptions (2, 3). At least 83 patients
need misoprostol prophylaxis to prevent one NSAID-related GI bleed,
although a subsequent systematic review was unable to calculate any figure
from the available evidence (4, 5)
Using Aronson’s table of what frequency qualifiers presently mean to
people, we would have to say that NSAIDs “never” cause the problems
described above, and the most effective prophylactic measure against these
risks “never” works. Well I never!
1 Aronson J. Sometimes, never. BMJ 2006;333:445
2. Blower AL, Brooks A, Fenn GC, Hill A, Pearce MY, Morant S, et al.
Emergency admissions for upper gastrointestinal disease and their relation
to NSAID use. Alimentary Pharmacology & Therapeutics 1997;11(2):283-
91.
3. Hawkey CJ, Cullen DJ, Greenwood DC, Wilson JV, Logan RF.
Prescribing of nonsteroidal anti-inflammatory drugs in general practice:
determinants and consequences. Alimentary Pharmacology & Therapeutics
1997;11(2):293-8.
5. Hooper L, Brown TJ, Elliott R, Payne K, Roberts C, Symmons D. The
effectiveness of five strategies for the prevention of gastrointestinal
toxicity induced by non-steroidal anti-inflammatory drugs: systematic
review. BMJ 2004;329:948. http://bmj.bmjjournals.com/cgi/content/full/329/7472/948 (Accessed 29
August 2006)
Competing interests:
None declared
Competing interests:
No competing interests
29 August 2006
John C Chambers
Macmillan Consultant and Medical Director
Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL
Strange things happen when we never qualify the frequency
Aronson illustrated that the definition of frequency qualifiers
cannot be taken for granted. (1) However, we often omit them completely as
we condense complex research findings into terse one-liners. This can
dramatically distort our perception of risk.
For example, nobody would disagree that non-steroidals (NSAIDs) are
an important cause of avoidable iatrogenic mortality in the elderly,
largely through ulceration and perforation of the upper gastrointestinal
tract. These ideas profoundly influence our prescribing: we may avoid
their use altogether or co-prescribe prophylactic measures.
Reputable studies suggest that, for NSAID users over the age of 75,
the annual risks for serious GI bleed and death are 1 in 110 and 1 in 650
respectively, and that there is one episode of ulcer bleeding in the
elderly for every 2,823 NSAID prescriptions (2, 3). At least 83 patients
need misoprostol prophylaxis to prevent one NSAID-related GI bleed,
although a subsequent systematic review was unable to calculate any figure
from the available evidence (4, 5)
Using Aronson’s table of what frequency qualifiers presently mean to
people, we would have to say that NSAIDs “never” cause the problems
described above, and the most effective prophylactic measure against these
risks “never” works. Well I never!
1 Aronson J. Sometimes, never. BMJ 2006;333:445
2. Blower AL, Brooks A, Fenn GC, Hill A, Pearce MY, Morant S, et al.
Emergency admissions for upper gastrointestinal disease and their relation
to NSAID use. Alimentary Pharmacology & Therapeutics 1997;11(2):283-
91.
3. Hawkey CJ, Cullen DJ, Greenwood DC, Wilson JV, Logan RF.
Prescribing of nonsteroidal anti-inflammatory drugs in general practice:
determinants and consequences. Alimentary Pharmacology & Therapeutics
1997;11(2):293-8.
4. Anon. GI complications and NSAIDs. Bandolier 1996;3(3):1-3.
http://www.jr2.ox.ac.uk/bandolier/band25/b25-1.html (Accessed 29 August
2006)
5. Hooper L, Brown TJ, Elliott R, Payne K, Roberts C, Symmons D. The
effectiveness of five strategies for the prevention of gastrointestinal
toxicity induced by non-steroidal anti-inflammatory drugs: systematic
review. BMJ 2004;329:948.
http://bmj.bmjjournals.com/cgi/content/full/329/7472/948 (Accessed 29
August 2006)
Competing interests:
None declared
Competing interests: No competing interests