From Dr H. K. Sinclair and others
SIR,—The risk of upper gastrointestinal bleeding and perforation associated
with non-steroidal anti-inflammatory drug (NSAID) use has been well documented,
whereas paracetamol has a reputation for good tolerability.
Moore et al conducted a randomised, controlled trial to compare the tolerability
of aspirin, ibuprofen and paracetamol for short-term analgesia in general practice.1
They concluded that the tolerability of ibuprofen was equivalent to that of
paracetamol and that “these findings could lead to the reassessment of
the use of first-line analgesics for the short-term management of painful conditions
in general practice, recommending ibuprofen first”. We feel there needs
to be additional evidence before this recommendation can be fully endorsed for
those self-medicating with over-the-counter (OTC) formulations of these analgesics.
Singh has expressed concern about the risk of OTC NSAIDs because of their widespread
use and the users’ under-appreciation of the true risk.2
We endorse his concerns. We have followed up 555 people who purchased ibuprofen
from community pharmacies and have identified instances of inappropriate use
with evidence of contraindications, drug interactions and
excessive dosing.3 The recommended daily dose (1,200mg)
was exceeded by 35 respondents (8 per cent) on at least one day and the recommended
maximum daily dose that can be prescribed by a physician (2,400mg) exceeded
on five occasions. During the seven days after the index purchase, ibuprofen
was used by 15 people (4 per cent) with an active or past history of stomach
or peptic ulcer, and 30 (7 per cent) with an active or past history of asthma.
Thirty-eight per cent had purchased ibuprofen for a chronic condition (>13
weeks’ duration) and 32 per cent were still taking it at the end of the
initial seven-day period.
A recent meta-analysis of studies reporting chronic (>two months) use of
NSAIDs estimated that these drugs are killing about 2,000 people each year in
the UK through gastric complications triggered by long-term use.4
Our pilot study found that 28 per cent of ibuprofen users had taken it for over
eight weeks. Those using it the longest (>20 weeks) were more likely to use
it regularly or continuously.
Inappropriate use is likely to cause side effects and to have cost implications
for the National Health Service. Herxheimer suggested that ignorance about possible
adverse effects of NSAIDs led to patients not recognising warning symptoms,
to inappropriate compliance and subsequent hospitalisation with acute gastrointestinal
bleeding.5 In our study, “ever users” (used any
ibuprofen during the six-months since their index purchase) were more likely
than “never users” to experience at least one gastrointestinal symptom,
a skin rash or itch or to consult a doctor.
There is a perception among some users that because ibuprofen is available OTC
it does not carry any significant risk. Further studies are required to inform
a programme to encourage health care professionals to ask routinely about use
of non-prescribed medicines and for users to be proactive in informing their
doctor. This will help health care professionals to identify individuals particularly
at risk of adverse events who should avoid these products, thus reducing NHS
costs, maximising the value of self-medication and improving patient care.
Hazel K. Sinclair
Research Fellow
Christine M. Bond
Professor of Primary Care (Pharmacy)
Philip C. Hannaford
Grampian Health Board Chairman of Primary Care
Department of General Practice and Primary Care,
University of Aberdeen,
Foresterhill Health Centre,
Westburn Road,
Aberdeen AB25 2AY