Incidence of clinically manifest ulcers and their complications in patients with rheumatoid arthritis

Background-Non-steroidal anti-inflammatory drugs (NSAIDs) are often prescri bed in patients with rheumatoid arthritis (RA). Because of its frequency an d severity, NSAID gastropathy is the most important side effect. The clinic al spectrum of NSAID gastropathy includes gastrointestinal complaints, ulce rs and their complications. To reduce NSAID gastropathy, rheumatologists in greater Amsterdam decided in January 1997 that prophylactic agents should be prescribed for patients with RA at high risk for NSAID gastropathy, defi ned as age 60 or older or a history of gastrointestinal (GI) ulcers, or bot h. Objective-To determine the incidence of clinically manifest ulcers and thei r complications in patients with RA at high risk for NSAID gastropathy duri ng a period in which prophylaxis was recommended. Published reports show th at the incidence of clinically manifest ulcers and their complications vari es from 1.3% to 5%. Patients and methods-Within one year; three questionnaires were sent to all outpatients with RA of our clinic (n=2680). The patients were asked if the y had had a gastroscopy and/or complication of an ulcer in the preceding mo nths. When a GI event (ulcer or complication) had occurred an analysis was carried out to determine whether the event was possibly related to a compli ance failure or a policy failure-for example, no prophylaxis prescribed whe n it was recommended. Results-The response rate for the three questionnaires was 88%, 76%, and 77 %, respectively. All three questionnaires were returned by 1856 patients; N SAIDs were used in 1246 (67%) of them. Of the NSAID users 731 (59%) were in the high risk group. Clinically manifest ulcers occurred in seven high ris k NSAID users (four gastric ulcers, two duodenal ulcers, and in one patient both types of ulcer). Complications of ulcers were diagnosed in eight (oth er) patients: seven (upper) GI bleedings and one perforation. Thus the inci dence during one year of clinically manifest ulcers in the high risk group was 1.0% and of complications of ulcers 1.1%, together 2.1%. In the group o f 15 patients with GI events, only one patient had not taken the adequately prescribed gastroprotective drugs (compliance failure). Misguidedly, gastr oprotective drugs were not prescribed in seven patients (policy failure), b ut in the remaining seven patients gastroprotective drugs were adequately p rescribed and used. Conclusion-The incidence of clinically manifest ulcers and of complications of ulcers in patients with RA at high risk for NSAID gastropathy is relati vely low, and might be related to our strategy to prescribe prophylactic ag ents in these patients.