LETTER
Misoprostol and Gastrointestinal Complications in Patients Taking Nonsteroidal Anti-Inflammatory Drugs for Rheumatoid Arthritis
Charles M. Grossman, MD
15 May 1996 | Volume 124 Issue 10 | Pages 926-927
TO THE EDITOR:
Silverstein and colleagues [1] describe a large number of patients in their study, yet the cited numbers of severe complications (25 definite events in the misoprostol group compared with 42 in the placebo group) are small. The authors state that the "40% reduction ... is maintained in patients with any of the four risk factors or combination of risk factors." The absolute numbers might have been presented to allow the reader to evaluate these subgroups, but such numbers would indeed be smaller and would not pass tests of statistical significance.
Some evidence suggests that enteric coated aspirin is effective and is not associated with a high risk for adverse effects [2]. Analgesic doses of enteric coated aspirin were effective in 436 patients with chronic rheumatoid arthritis and were associated with almost no risk for severe gastrointestinal complications [3]. Silverstein and colleagues' study included 632 patients receiving aspirin, but enteric coated aspirin is not mentioned.
A local pharmacy indicated that the monthly patient cost of enteric coated aspirin (300 tablets) is $8.00. The cost for comparable doses of ibuprofen was $16.50. Other NSAIDs cost from $23.00 to $70.00 per month at usual doses. Patients vary, and some who may not get relief from enteric coated aspirin do respond to another NSAID. Why do the authors emphasize the use of the more expensive NSAIDs? Adding $90.00 per month for misoprostol to prevent a few severe complications is hardly logical, as pointed out in Dr. Levine's editorial [4].
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Author and Article Information
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Portland, OR 97205
1. Silverstein FE, Graham DY, Senior JR, Wyn Davies H, Struthers BJ, Bittman RM, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995; 123:241-9.
2. Grossman CM. NSAIDs and gut toxicity [Letter]. Lancet. 1995; 344:57.
3. Fries JF, Ramey DR, Singh G, Morfeld D, Block DA, Reynauld JP. A re-evaluation of aspirin therapy in rheumatoid arthritis. Arch Intern Med. 1993; 153:2465-71.
4. Levine JS. Misoprostol and nonsteroidal anti-inflammatory drugs: a tale of effects, outcomes, and costs [Editorial]. Ann Intern Med. 1995; 123:309-10.
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