Determinants of self-medication with NSAIDs in a Portuguese community pharmacy

Main Article Content

Keywords

Anti-Inflammatory Agents, Non-Steroidal, Drug-Related Side Effects and Adverse Reactions, Pharmacies, Cross-Sectional Studies, Portugal

Abstract

Background: Non-steroid anti-inflammatory drugs (NSAIDs) are a widely used therapeutic group in the world, and particularly in the Portuguese population.

Objective: To compare NSAID’s use by prescription and self-medication acquisition and to determine the pattern of indication of NSAIDs, their usage profile and possible implications for patients’ safety.

Methods: A cross-sectional design was used where individuals presenting at a community pharmacy requesting NSAIDs during the study period (one month) were invited to answer a face-to-face interview where socio-demographic characteristics, the indication pattern and previous experience of side effects were assessed. A follow-up interview was performed one week later to assess the incidence of adverse effects. The study was ethically approved.

Results: A sample of 130 NSAIDs users was recruited, comprising mostly women (n=87; 66.9%), actively employed (n=77; 59.2%) and presenting a mean age of 49.5 years old (SD=20.49). An equal proportion of individuals acquired NSAIDs by self-medication and with medical prescription (n=65; 50%). Over 4/5 of patients (n=57; 87.7%) acquiring NSAIDs without a prescription were self-medicated by their own initiative, and only 10.8% (n=7) had been advised by the pharmacist. The most commonly acquired active substances were ibuprofen and diclofenac. Self-medicated users more frequently resorted to topical NSAIDs following short term treatments. The major underlying condition motivating NSAIDs sought were musculoskeletal disorders (45.0%), regardless of the regimen. An important proportion of prevalent users of NSAIDs reported previous experience of adverse effects (11.3%). One week after initiating NSAID therapy, a small proportion of patients reported incidence of adverse effects.

Conclusion: Self-medication with NSAIDs is sought for numerous medical conditions. Reported adverse effects (prevalent and incident) confirm the need for a more rational use of NSAIDs and ongoing pharmacovigilance.

Abstract 2423 | PDF Downloads 1421

References

1. Couto G, Macedo G, Ribeiro F. [Upper gastrointestinal bleeding associated with acetylsalicylic acid Results from PARAINES study]. J Port Gastroenterol. 2010;17:200-206.

2. Day RO, Graham GG. Republished research: Non-steroidal anti-inflammatory drugs (NSAIDs). Br J Sports Med. 2013;47(17):1127. doi: 10.1136/bjsports-2013-f3195rep

3. Dietrich T, Leeson R, Gugliotta B, Petersen B. Efficacy and safety of low dose subcutaneous diclofenac in the management of acute pain: a randomized double-blind trial. Pain Pract. 2014;14(4):315-323. doi: 10.1111/papr.12082

4. Ministério da Saúde. Portaria n.o 924-A/2010, de 17 de setembro (2010). Diário da República n.o 182 - I Série. Lisboa.

5. Ministério da Saúde. Lisboa. Decreto-Lei n.o 134/2005. Diário da República - I Série-A - no 156. 2005;4763–5.

6. INFARMED. Estatistica do Medicamento 2013. Lisboa: INFARMED; 2015.

7. Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, Pirmohamed M. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol. 2007;63(2):136-147.

8. Observatório Português dos Sistemas de Saúde. Duas Faces da Saúde - Relatório de Primavera 2013. Lisboa: OPSS; 2013.

9. Motola D, Vaccheri A, Silvani MC, Poluzzi E, Bottoni A, De Ponti F, Montanaro N. Pattern of NSAID use in the Italian general population: A questionnaire-based survey. Eur J Clin Pharmacol. 2004;60(10):731-738

10. Barkin RL, Beckerman M, Blum SL, Clark FM, Koh E-K, Wu DS. Should nonsteroidal anti-inflammatory drugs (NSAIDs) be prescribed to the older adult? Drugs Aging. 2010;27(10):775-789. doi: 10.2165/11539430-000000000-00000

11. Stegemann S, Ecker F, Maio M, Kraahs P, Wohlfart R, Breitkreutz J, Zimmer A, Bar-Shalom D, Hettrich P, Broegmann B. Geriatric drug therapy: Neglecting the inevitable majority. Ageing Res Rev. 2010;9(4):384-398. doi: 10.1016/j.arr.2010.04.005

12. Franceschi M, Di Mario F, Leandro G, Maggi S, Pilotto A. Acid-related disorders in the elderly. Best Pract Res Clin Gastroenterol. 2009;23(6):839-848. doi: 10.1016/j.bpg.2009.10.004

13. Ubeda A, Ferrándiz ML, Maicas N, Gomez C, Bonet M, Peris JE. Potentially inappropriate prescribing in institutionalised older patients in Spain: the STOPP-START criteria compared with the Beers criteria. Pharm Pract (Granada). 2012;10(2):83-91.

14. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): Application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing. 2008;37(6):673-9. doi: 10.1093/ageing/afn197

15. Campanelli CM. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. doi: 10.1111/j.1532-5415.2012.03923.x

16. Lanza FL. A guideline for the treatment and prevention of NSAID-induced ulcers. Members of the Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol. 1998;93(11):2037-2046.

17. Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012;9:CD007400. doi: 10.1002/14651858.CD007400.pub2

18. Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FK, Furberg CD, Johnson DA, Mahaffey KW, Quigley EM; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: A report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents. Circulation. 2008;118(18):1894-1909. doi: 10.1161/CIRCULATIONAHA.108.191087

19. Batlouni M. [Nonsteroidal anti-inflammatory drugs: cardiovascular, cerebrovascular and renal effects]. Arq Bras Cardiol. 2010;94(4):556-563.

20. Tazi K, Hathaway A, Chiuzan C, Shirai K. Survival of melanoma patients with brain metastases treated with ipilimumab and stereotactic radiosurgery. Cancer Med. 2015;4(1):1-6. doi: 10.1002/cam4.315

21. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Epidemiology. 2007;18(6):805-835.

22. Ministério da Saúde. Lisboa. Decreto-Lei no 307/2007 de 31 de Agosto de 2007. Diário da República - I Série- no 168/2007. 2007;6083.

23. Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain. Clin Infect Dis. 2009;48(10):1345-1349. doi: 10.1086/598183

24. Bartlett C, Doyal L, Ebrahim S, Davey P, Bachmann M, Egger M, Dieppe P. The causes and effects of socio-demographic exclusions from clinical trials. Health Technol Assess. 2005 Oct;9(38):1-152.

25. Kovac SH, Saag KG, Curtis JR, Allison J. Association of health-related quality of life with dual use of prescription and over-the-counter nonsteroidal antiinflammatory drugs. Arthritis Rheum. 2008;59(2):227-233. doi: 10.1002/art.23336

26. Mendes Z, Martins AP, Miranda C, Soares MA, Ferreira AP, Nogueira A. Self-medication prevalence in a Portuguese urban area]. Rev Bras Ciências Farm. 2004;40(1):3-7.

27. Koffeman AR, Van Buul AR, Valkhoff VE, Jong GW, Bindels PJ, Sturkenboom MC, Van der Lei J, Luijsterburg PA, Bierma-Zeinstra SM. drug reactions in a primary care population prescribed non-steroidal antiinflammatory drugs. Scand J Prim Health Care. 2015;33(3):163-169. doi: 10.3109/02813432.2015.1067513

28. Torres Rde C, Marques KS, Leal Kde N, Rocha-Filho PA.Main reasons for medical consultations in family healthcare units in the city of Recife, Brazil: a cross-sectional study. Sao Paulo Med J. 2015;133(4):367-370. doi: 10.1590/1516-3180.2014.9490902

29. Valkhoff VE, Schade R, 't Jong GW, Romio S, Schuemie MJ, Arfe A, Garbe E, Herings R, Lucchi S, Picelli G, Schink T, Straatman H, Villa M, Kuipers EJ, Sturkenboom MC; Safety of Non-steroidal Anti-inflammatory Drugs (SOS) project. Population-based analysis of non-steroidal anti-inflammatory drug use among children in four European countries in the SOS project: what size of data platforms and which study designs do we need to assess safety issues? BMC Pediatr. 2013;13:192. doi: 10.1186/1471-2431-13-192

30. Ordem dos Farmacêuticos. [Good Pharmacy Practice for community pharmacy]. Associação Nacional das Farmácias, Grupo Farmacêutico da União Europeia. Lisboa. 2009.

31. Coelho RB, Costa FA. Impact of pharmaceutical counseling in minor health problems in rural Portugal. Pharm Pract (Granada). 2014;12(4):451.

32. Koffeman AR, Valkhoff VE, Celik S, W't Jong G, Sturkenboom MC, Bindels PJ, van der Lei J, Luijsterburg PA, Bierma-Zeinstra SM. High-risk use of over-the-counter non-steroidal anti-inflammatory drugs: a population-based cross-sectional study. Br J Gen Pract. 2014;64(621):e191-e198. doi: 10.3399/bjgp14X677815

33. Hughes CM, Hawwa AF, Scullin C, Anderson C, Bernsten CB, Björnsdóttir I, Cordina MA, da Costa FA, De Wulf I, Eichenberger P, Foulon V, Henman MC, Hersberger KE, Schaefer MA, Søndergaard B, Tully MP, Westerlund T, McElnay JC. Provision of pharmaceutical care by community pharmacists: a comparison across Europe. Pharm World Sci. 2010;32(4):472-487. doi: 10.1007/s11096-010-9393-x

34. Argoff CE, Gloth FM. Topical nonsteroidal anti-inflammatory drugs for management of osteoarthritis in long-term care patients. Ther Clin Risk Manag. 2011;7:393-399. doi: 10.2147/TCRM.S24458

35. Underwood M, Ashby D, Carnes D, Castelnuovo E, Cross P, Harding G, Hennessy E, Letley L, Martin J, Mt-Isa S, Parsons S, Spencer A, Vickers M, Whyte K. Topical or oral ibuprofen for chronic knee pain in older people. The TOIB study. Health Technol Assess. 2008;12(22):1-155.

36. Fuller P, Roth S. Diclofenac sodium topical solution with dimethyl sulfoxide, a viable alternative to oral nonsteroidal anti-inflammatories in osteoarthritis: review of current evidence. J Multidiscip Healthc. 2011;4:223-231. doi: 10.2147/JMDH.S23209

37. Kienzler JL, Gold M, Nollevaux F. Systemic bioavailability of topical diclofenac sodium gel 1% versus oral diclofenac sodium in healthy volunteers. J Clin Pharmacol. 2010;50(1):50-61. doi: 10.1177/0091270009336234

38. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal antiinflammatory drugs: An update for clinicians: A scientific statement from the American Heart Association. Circulation. 2007;115(12):1634-1642.

39. Calado G, Gaspar Marques J, Chambel M, Martins P, Leiria Pinto P. [Nonsteroidal anti-inflammatory drugs hypersensitivity in pediatric patients with asthma]. Rev Port Imunoalergologia. 2012;20(4):273-280.

40. INFOMED. Resumo das Características do medicamento Exxiv. 2013; Available from: http://www.infarmed.pt/infomed/download_ficheiro.php?med_id=34063&tipo_doc=rcm (accessed on 1-Jul-2015).

41. Instituto Nacional de Estatística IP. Censos 2011. Censos 2011 Resultados Definitivos. Portugal. Lisboa: INE; 2012.

42. Teichert M, Griens F, Buijs E, Wensing M, De Smet PA. Effectiveness of interventions by community pharmacists to reduce risk of gastrointestinal side effects in nonselective nonsteroidal anti-inflammatory drug users. Pharmacoepidemiol Drug Saf. 2014;23(4):382-389. doi: 10.1002/pds.3587