Información del artículo
Abstract
Objectives
To analyze the safety of combining non-steroidal anti-inflammatory drugs (NSAID) and steroids.
MethodsA systematic review following a sensitive search strategy was performed. All articles published in MEDLINE (since 1961), EMBASE (since 1961), and Cochrane Library, up to December 2007 were examined. Selection criteria: the population (subjects with musculoskeletal diseases on steroids), the intervention (concomitant use of NSAID), and outcomes related to drugs safety (gastrointestinal, renal, and cardiovascular toxicity). Titles and abstracts of retrieved articles meeting inclusion criteria from the search were reviewed. Only randomized controlled trials (RCT) or high quality cohort studies with a control group were included.
ResultsOf a total of 4164 references retrieved, 42 were analyzed in detail, and 10 were finally included, 6 RCT and 4 prospective cohort studies, which included more than 20 000 patients.
ConclusionsThe use of NSAID and low dose of steroids in patients with musculoskeletal diseases does not seem to increase the risk of gastrointestinal adverse events.
Key words:
Non-steroidal anti-inflammatory drugs
Steroids
Safety
Resumen
Objetivos
Analizar la seguridad del uso concomitante de antiinflamatorios no esteroideos (AINE) con esteroides en pacientes con enfermedad reumática.
MétodosRevisión sistemática. Se definió una estrategia de búsqueda bibliográfica sensible en MEDLINE (desde 1961), EMBASE (desde 1980) y Cochrane Library hasta diciembre del 2007, definiendo la población (sujetos con enfermedad reumática en tratamiento con esteroides) y la intervención (tratamiento concomitante con AINE) y definiendo como resultados variables de seguridad (toxicidad gastrointestinal, renal y cardiovascular). Se seleccionaron ensayos clínicos y estudios de cohortes de calidad.
ResultadosSe recuperaron 4.164 estudios, de los que 42 se analizaron en detalle; finalmente se incluyeron 10 en los análisis, 6 de los cuales fueron ensayos clínicos y 4, estudios de cohortes prospectivos, que incluyeron a más de 20.000 pacientes.
ConclusionesEl uso concomitante de AINE y esteroides a dosis bajas en pacientes con enfermedad reumática no parece que incremente el riesgo de eventos adversos gastrointestinales.
Palabras clave:
Antiinflamatorios no esteroideos
Esteroides
Seguridad
El Texto completo está disponible en PDF
References
[1.]
A. Lanas.
[Advances in the adverse effects of NSAIDs in the gastrointestinal tract].
Gastroenterol Hepatol, 29 (2006), pp. 16-22
[2.]
S.E. Gabriel, L. Jaakkimainen, C. Bombardier.
Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis.
Ann Intern Med, 115 (1991), pp. 787-796
[3.]
L.A. Garcia Rodriguez, S. Hernandez-Diaz.
The risk of upper gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs, glucocorticoids, acetaminophen, and combinations of these agents.
Artritis Res, 3 (2001), pp. 98-101
[4.]
A.R. Jadad, R.A. Moore, D. Carroll, C. Jenkinson, D.J. Reynolds, D.J. Gavaghan, et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?.
Control Clin Trials, 17 (1996), pp. 1-12
[5.]
J.L. Goldstein, P. Correa, W.W. Zhao, A.M. Burr, R.C. Hubbard, K.M. Verburg, et al.
Reduced incidence of gastroduodenal ulcers with celecoxib, a novel cyclooxygenase-2 inhibitor, compared to naproxen in patients with arthritis.
Am J Gastroenterol, 96 (2001), pp. 1019-1027
[6.]
H. Jick, R.S. Pinals, R. Ullian, D. Slone, H. Muench.
Dexamethasone and dexamethasone-aspirin in the treatment of chronic rheumatoid arthritis. A controlled trial.
Lancet, 2 (1965), pp. 1203-1205
[7.]
L. Laine, C. Bombardier, C.J. Hawkey, B. Davis, D. Shapiro, C. Brett, et al.
Stratifying the risk of NSAID-related upper gastrointestinal clinical events: results of a double-blind outcomes study in patients with rheumatoid arthritis.
Gastroenterology, 123 (2002), pp. 1006-1012
[8.]
L. Laine, L.G. Connors, A. Reicin, C.J. Hawkey, R. Burgos-Vargas, T.J. Schnitzer, et al.
Serious lower gastrointestinal clinical events with nonselective NSAID or coxib use.
Gastroenterology, 124 (2003), pp. 288-292
[9.]
B.H. Littman, D. Bjarnason, G. Bryant, J. Engelbrecht, M. Cohen, L. Mertz, et al.
Steroid sparing activity of tenidap in patients with polymyalgia rheumatica: a multicenter double blind randomized placebo controlled study.
J Rheumatol, 22 (1995), pp. 1097-1103
[10.]
H.E. Paulus, D. Di Primeo, M. Sanda, J.M. Lynch, B.A. Schwartz, J.T. Sharp, et al.
Progression of radiographic joint erosion during low dose corticosteroid treatment of rheumatoid arthritis.
J Rheumatol, 27 (2000), pp. 1632-1637
[11.]
E. Benito-Garcia, K. Michaud, F. Wolfe.
The effect of low-dose aspirin on the decreased risk of development of dyspepsia and gastrointestinal ulcers associated to cyclooxygenase-2 selective inhibitors.
J Rheumatol, 34 (2007), pp. 1765-1769
[12.]
J.F. Fries, P.W. Spitz, D.A. Bloch, et al.
Factors in the duration and discontinuation of treatment with nonsteroidal anti-inflammatory medications.
Clin Ther, 13 (1991), pp. 51-62
[13.]
S.E. Gabriel, J. Sunku, C. Salvarani, W.M. O’Fallon, G.G. Hunder.
Adverse outcomes of antiinflammatory therapy among patients with polymyalgia rheumatica.
Arthritis Rheum, 40 (1997), pp. 1873-1878
[14.]
F. Wolfe, D.J. Hawley.
The comparative risk and predictors of adverse gastrointestinal events in rheumatoid arthritis and osteoarthritis: a prospective 13 year study of 2131 patients.
J Rheumatol, 27 (2000), pp. 1668-1673
[15.]
S. Hernandez-Diaz, L.A. Rodriguez.
Steroids and risk of upper gastrointestinal complications.
Am J Epidemiol, 153 (2001), pp. 1089-1093
[16.]
M.B. Abelson, L.M. Smith, L.D. Ormerod.
Prospective, randomized trial of oral piroxicam in the prophylaxis of postoperative cystoid macular edema.
J Ocul Pharmacol, 5 (1989), pp. 147-153
[17.]
U. Ambanelli, A. Nervetti, B. Colombo, G. Cherie-Ligniere, I. Gualdi, R. Marcolongo, et al.
Beta-cyclodextrin-piroxicam in the treatment of rheumatic diseases: a prospective study.
J Drug Development, 4 (1991), pp. 55-66
[18.]
B. Avidan, A. Sonnenberg, T.G. Schnell, E. Budiman-Mak, S. Sontag.
Risk factors of oesophagitis in arthritic patients.
Eur J Gastroenterol Hepatol, 13 (2001), pp. 1095-1099
[19.]
W.M. Awni, J.H. Cavanaugh, T.B. Tzeng, G. Witt, G.R. Granneman, L.M. Dube.
Pharmacokinetic interactions between zileuton and prednisone.
Clin Pharmacokinet, 29 (1995), pp. 105-111
[20.]
J.J. Badia Flores, S. Valdez Rojas.
Naproxen: corticosteroid-sparing effect in rheumatoid arthritis.
J Clin Pharmacol, 15 (1975), pp. 373-377
[21.]
D.E. Bowers, H.R. Dyer, W.M. Fosdick, K.E. Keller, A.L. Rosenberg, P. Sussman, et al.
Naproxen in rheumatoid arthritis. A controlled trial.
Ann Intern Med, 83 (1975), pp. 470-475
[22.]
J.B. del Campo.
Double-blind multicentre, between patients comparison of indoprofen and indomethacin in rheumatoid arthritis patients under basic steroid treatment.
Eur J Rheumatol Inflamm, 4 (1981), pp. 135-143
[23.]
J.B. Flores.
[Naproxen: Corticosteroid sparing effect in rheumatoid arthritis].
Scand J Rheumatol, 2 (1973), pp. 127-131
[24.]
R. Furtado, L.M. Oliveira, J. Natour.
Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study.
J Rheumatol, 32 (2005), pp. 1691-1698
[25.]
E.B. Garcia, K. Michaud, F. Wolfe.
Gastrointestinal prophylactic therapy among patients with arthritis treated by rheumatology specialists.
J Rheumatol, 33 (2006), pp. 779-784
[26.]
V. Garg, R. Blum, K.D. Wilner, W.J. Jusko.
Effect of the anti-inflammatory agent tenidap on the pharmacokinetics and pharmacodynamics of prednisolone.
J Clin Pharmacol, 32 (1992), pp. 222-230
[27.]
P. Gergely.
Treatment of systemic lupus erythematosus (SLE) with piroxicam (Hotemin-Egis).
Ther Hung, 37 (1989), pp. 83-85
[28.]
M.V. Goycochea-Robles, C.A. Arce-Salinas, S. Guzman-Vazquez, M. Cardiel-Rios.
Prescription rheumatology practices among mexican specialists.
Arch Med Res, 38 (2007), pp. 354-359
[29.]
S. Green, R. Buchbinder, R. Glazier, A. Forbes.
Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy.
BMJ, 316 (1998), pp. 354-360
[30.]
C.L. Harris, D.W. Raisch, U. Abhyankar, S. Marfatia, H.M. Campbell, M.R. Sather.
GI risk factors and use of GI protective agents among patients receiving nonsteroidal antiinflammatory drugs.
Ann Pharmacother, 40 (2006), pp. 1924-1931
[31.]
A. Helin-Salmivaara, R. Huupponen, A. Virtanen, J. Lammela, T. Klaukka.
Frequent prescribing of drugs with potential gastrointestinal toxicity among continuous users of non-steroidal anti-inflammatory drugs.
Eur J Clin Pharmacol, 61 (2005), pp. 425-431
[32.]
P. Hochain, I. Berkelmans, P. Czernichow, C. Duhamel, J. Tranvouez, E. Lerebours, et al.
Which patients taking non-aspirin non-steroidal anti-inflammatory drugs bleed? A case-control study.
Eur J Gastroenterol Hepatol, 7 (1995), pp. 419-426
[33.]
J. Holvoet, L. Terriere, W. van Hee, L. Verbist, E. Fierens, M.L. Hautekeete.
Relation of upper gastrointestinal bleeding to non-steroidal anti-inflammatory drugs and aspirin: a case-control study.
Gut, 32 (1991), pp. 730-734
[34.]
C. Huerta, J. Castellsague, C. Varas-Lorenzo, L.A. Garcia Rodriguez.
Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population.
Am J Kidney Dis, 45 (2005), pp. 531-539
[35.]
V.R. Joshi, R.D. Lele, A.R. Virani, H.K. Nagarwala, P.K. Pispati, M.M. Desai.
Steroid-sparing action of flurbiprofen: use of an additional parameter of joint scans with 99m technetium.
Curr Med Res Opin, 5 (1977), pp. 43-47
[36.]
M.N. Kolopp-Sarda, F. Guillemin, I. Chary-Valckenaere, M.C. Bene, J. Pourel, G.C. Faure.
Longitudinal study of rheumatoid arthritis patients discloses sustained elevated serum levels of soluble cd106 (v-cam).
Clin Exp Rheumatol, 19 (2001), pp. 165-170
[37.]
M. Komajda, F. Follath, K. Swedberg, J. Cleland, J.C. Aguilar, A. Cohen-Solal, et al.
The EuroHeart Failure Survey programme-a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment.
Eur Heart J, 24 (2003), pp. 464-474
[38.]
B.G. Lanier, R.A. Turner Jr., R.L. Collins, R.G. Senter Jr..
Evaluation of nabumetone in the treatment of active adult rheumatoid arthritis.
Am J Med, 83 (1987), pp. 40-43
[39.]
S. Luftschein, H. Bienenstock, J.C. Varady, F.W. Stitt.
Increasing dose of naproxen in rheumatoid arthritis: use with and without corticosteroids.
J Rheumatol, 6 (1979), pp. 397-404
[40.]
R.O. Martinez, H. Casas, P.A. Mazure, H. Leczycki, J.N. Cosen, L. Canievsky, et al.
[Gastroduodenal lesions in rheumatoid arthritis. Evaluation and treatment].
Acta Gastroenterol Latinoam, 18 (1988), pp. 87-96
[41.]
J. Martio.
The influence of antirheumatic drugs on the occurrence of peptic ulcers. A controlled study of patients with chronic rheumatic diseases.
Scand J Rheumatol, 9 (1980), pp. 55-59
[42.]
V. McNeil.
NSAID's – a double-edged sword.
Hosp Pharm, 28 (1993), pp. 50-55
[43.]
D.H. Neustadt.
Double blind evaluation of the long-term effects of etodolac versus ibuprofen in patients with rheumatoid arthritis.
J Rheumatol, 47 (1997), pp. 17-22
[44.]
H.E. Paulus, D. Di Primeo, J.T. Sharp, H.K. Genant, B.N. Weissman, M.H. Weisman, et al.
Patient retention and hand-wrist radiograph progression of rheumatoid arthritis during a 3-year prospective study that prohibited disease modifying antirheumatic drugs.
J Rheumatol, 31 (2004), pp. 470-481
[45.]
V. Rejholec, H. Vapaatalo, O. Tokola, G. Gothoni.
Tolfenamic acid in the treatment of rheumatoid arthritis.
Scand J Rheumatol, 24 (1979), pp. 9-12
[46.]
P. Sheldon.
Ileum-targeted steroid therapy in rheumatoid arthritis: doubleblind, placebo-controlled trial of controlled-release budesonide.
Rheumatol Int, 23 (2003), pp. 154-158
Copyright © 2008. Sociedad Española de Reumatología and Colegio Mexicano de Reumatología
