Pain Management: Peptic Ulcer Disease, Kidney Disease, and Coronary Heart Disease

00:01 And just to pay attention to a few critical illnesses, as we think about treatment of mild to moderate pain, one is gastric ulcers.

00:09 There was a classic study that performed endoscopy on patients who have been taking NSAIDs, they found that there was some evidence of gastric ulceration in 30% of those patients.

00:20 Those aren't usually serious gastric ulcers that produce symptoms, but nonetheless we always have to be aware of chronic NSAID use and the risk for a gastrointestinal ulcer and gastrointestinal bleeding.

00:31 There is two opposing trends.

00:33 First of all, H. pylori has been more recognized and now more is being treated.

00:38 So, that's driving the rate of peptic ulcers down.

00:41 However, more people are using NSAIDs on a chronic basis, particularly older adults who are already at risk for ulcer.

00:48 That's driving the risk of ulcers up.

00:50 So, overall, the prevalence of ulcers has remained about the same.

00:56 They account for up to 2.5% of all admissions.

01:00 But if you talk to patients and ask them, has a doctor ever told you had peptic ulcer in the past? About 10% will say that they had that diagnosis in the past.

01:10 So, there’s a disconnect there between admissions and a broader number of patients who've been diagnosed with PUD.

01:17 Risk factors for peptic ulcer include older age, low educational attainment, low family income, history of smoking and, as I mentioned, chronic NSAID use.

01:26 And the one I think we can do most about as clinicians is chronic NSAID use.

01:32 What about kidney disease? So, there is a link between NSAID use and kidney disease, but that doesn’t mean that if you're a 28-year-old playing basketball and you sprain your wrist and you take ibuprofen for a week that you’re going to have a significantly increased risk of kidney disease.

01:52 That's not going to happen.

01:53 Young healthy people, it’s pretty safe to take intermittent NSAIDs.

01:56 However, among patients who are over 65, taking NSAIDs, instead of acetaminophen, is associated with 34% increase in the risk of renal impairment, and that is dramatically increased if coronary artery disease is also present.

02:13 So, really, be cognizant of older adults and adults with comorbid conditions that are frequently associated with kidney disease.

02:21 NSAIDs can really do damage to the kidney in those patients.

02:26 What about coronary heart disease? So, this is a study of nearly 62,000 adults, all of whom had a first-time myocardial infarction.

02:34 So, mostly men, mostly older, as you'd expect.

02:37 And so, what they're looking for here were two rates.

02:40 Among those patients with a myocardial infarction, what were the rates of bleeding among those who did and did not receive an NSAID after their myocardial infarction? What were the rate of cardiovascular events among those who did and did not receive an NSAID? And so, what they found not shockingly, their bleeding is in green here, that there was about twofold risk in the risk of bleeding among patients with -- who received an NSAID and had a history of myocardial infarction, but there was also a 40% increase in the rate of recurrent cardiovascular events associated with NSAID use as well.

03:18 So, this makes it appear that NSAIDs may promote a higher risk of repeat cardiovascular events among patients with known myocardial infarction.