Joyce M. Piper

Nonsteroidal Anti-inflammatory Drug Use and Increased Risk for Peptic Ulcer Disease in Elderly Persons

OBJECTIVE To evaluate the relative risk for peptic ulcer disease that is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. DESIGN Nested case-control study. SETTING Tennessee Medicaid program. PARTICIPANTS Medicaid enrollees 65 years of age or older were included in the study. The 1415 case patients had been hospitalized for confirmed peptic ulcer disease at some point from 1984 through 1986. The 7063 control persons represented a stratified random sample of other Medicaid enrollees. MEASUREMENTS AND MAIN RESULTS The estimated relative risk for the development of peptic ulcer disease among current users of nonaspirin nonsteroidal anti-inflammatory drugs, compared with that among nonusers, was 4.1 (95% CI, 3.5 to 4.7). For current users, the risk increased with increasing dose, from a relative risk of 2.8 (CI, 1.8 to 4.3) for the lowest to a relative risk of 8.0 (CI, 4.4 to 14.8) for the highest dose category. The risk was greatest in the first month of use (relative risk, 7.2; CI, 4.9 to 10.5). If the association is fully causal, 29% of peptic ulcers in the study sample resulted from the use of these drugs, and the excess risk associated with such use was 17.4 hospitalizations for ulcer disease per 1000 person-years of exposure. CONCLUSIONS These data support other findings indicating that a clinically significant risk for serious ulcer disease is associated with the use of nonaspirin nonsteroidal anti-inflammatory drugs. The data show that this risk increases with dose and recency of use and that use of these drugs may be responsible for a large proportion of peptic ulcer disease among elderly persons.

corticosteroid Use and Peptic Ulcer Disease: Role of Nonsteroidal Anti-inflammatory Drugs

OBJECTIVE To estimate the relative risk for peptic ulcer disease that is associated with the use of oral corticosteroids. DESIGN A nested case-control study. SETTING Tennessee Medicaid program. PARTICIPANTS The case patients (n = 1415) were hospitalized between 1984 and 1986 for gastric or duodenal ulcer or for upper gastrointestinal hemorrhage of unknown cause. The controls (n = 7063) were randomly selected from Medicaid enrollees not meeting the study criteria for inclusion as case patients. MEASUREMENTS AND MAIN RESULTS The estimated relative risk for the development of peptic ulcer disease among current users of oral corticosteroids was 2.0 (95% CI, 1.3 to 3.0). However, the risk was increased only in those who concurrently received nonsteroidal anti-inflammatory drugs (NSAIDs); these persons had an estimated relative risk associated with current corticosteroid use of 4.4 (CI, 2.0 to 9.7). In contrast, the estimated relative risk for those corticosteroid users not receiving NSAIDs was 1.1 (CI, 0.5 to 2.1). Persons concurrently receiving corticosteroids and NSAIDs had a risk for peptic ulcer disease that was 15 times greater than that of nonusers of either drug. CONCLUSION Discrepant findings among earlier studies regarding steroids and the risk for peptic ulcer disease could in part be due to differences in the use of NSAIDs among study participants. The high risk for peptic ulcer disease associated with combined use of NSAIDs and corticosteroids indicates the need to prescribe this drug combination cautiously.

Evaluation of a program for prenatal care case management.

A prenatal care case-management program in Tennessee was evaluated to determine its effectiveness in improving the adequacy of prenatal care reducing the odds of preterm birth (gestation less than 37 weeks) and very low birth weight births (less than 1,500 g). The case-management program, Project HUG, included care provider referrals, visit scheduling, assistance with transportation and nutritional and health education. In a cohort of 66,051 Medicaid women with a birth during the period July 1989 through December 1991, 6% received HUG services. HUG participants had improved utilization of prenatal care, significantly decreased odds of inadequate perinatal care (an odds ratio of 0.71) and significantly increased odds of obtaining prenatal vitamins within 120 days of the last menstrual period (1.79). The apparent benefit of Project HUG was greater among blacks than among whites. However, there was no significant reduction in the incidence of preterm births or very low birth weight births among program participants

Maternal use of prescribed drugs associated with recognized fetal adverse drug reactions

To quantitate the frequency of exposure in pregnancy to selected drugs listed by the American Medical Associations Department of Drugs as having known or suspected association with fetal adverse drug reactions, we examined the prescription records of 18,886 Michigan Medicaid recipients who delivered a liveborn infant between April 1, 1981, and March 31, 1983. Focusing only on specific trimesters considered risk periods for each drug-fetal occurrence of adverse drug reaction, the use of tetracyclines during the first trimester of pregnancy was the most prevalent (21.3 exposed women/1000) prescribed drug associated with known or suspected fetal adverse drug reactions. The second most prevalent was phenobarbital in the first trimester, with 10.8 women exposed/1000. Following a close third was the use of the sulfonamides in the second trimester, with 10.0 women exposed/1000. The prescribing of nitrofurantoin and the sulfonamides in the last trimester and tetracyclines throughout pregnancy appears excessive. There are few indications for the outpatient use of the tetracyclines during pregnancy. Practitioners caring for pregnant women need to carefully evaluate the need for these drugs and consider when risks may outweigh benefits.

Status Report on the US Human Growth Hormone Recipient Follow-Up Study

Three reported cases of Creutzfeldt-Jakob disease (CJD) in young adults who had received human growth hormone (hGH) raised concerns that pituitary-derived GH had been contaminated. Subsequently reported cases have confirmed this suspicion. The US Public Health Service is conducting an investigation to determine the extent of the problem of CJD in recipients of National Hormone Pituitary Program (NHPP) GH. In addition, other possible adverse effects of GH use including leukemia are being investigated. The design, conduct and current status of the study are the subject of this report. Interview data are now available on 5,240 of the 6,284 subjects treated by the NHPP for growth problems. Analysis is underway.