e/c NSAIDS

[mm45]

A pharmacology lecturer recently told me that prescribing of e/c NSAIDs was just a waste of money compared to normal NSAIDs as they have no benefit to protecting the stomach as the drug still enters the system and acts on the stomach.

I just wondered if people agree with this...

[pharmatron]

It's not a case of whether people agree or not - it's fact!

Aspirin (salicylic acid) is a weak acid: it's local irritant effect is negligible in the acidic environment of the stomach (hydrochloric acid, pH~2). However, it has a profound effect on prostaglandin synthesis (permanently acetylates the cyclo-oxygenase enzyme).

PGs are essential for maintaining microvasculature and lining of the mucosa - hence aspirin causes GI irritation. This is a systemic effect not a local one consequently enteric coating will not prevent its occurence.

(The same is true for other ulcerogenic drugs e.g. prednisolone - EC will not solve the problem despite what many prescribers think!)

[johnep]

NSAIDs

My wife was precribed Celebrex for her arthritis. worked well but started suffering from stomach ache and had GI bleed. Could not believe that Celebrex to blame and she ended up with a sigmoidoscopy. This found a bleeding point (not a cancer as feared) and after stopping celebrex and a course of omeprazole--all Ok. She now takes ibuprofen but still needs an omeprazole.

I had problems after a combination of aspirin plus a whisky, so now I am on lansoprazole as keeping aspirin 300mg and Ibu 400mg going to relieve arthritis.

when I was young prided myself on my 'cast iron' stomach.

johnep

[mm45]

yeah I relise the fact that NSAIDs inhibit PG synthesis and mucous secretion etc. But if e/c are no more benefitical then normal NSAID why are so many doctors prescribing them, surely it could save the nhs money if they just stuck to the normal coating...

[admin]

yeah I relise the fact that NSAIDs inhibit PG synthesis and mucous secretion etc. But if e/c are no more benefitical then normal NSAID why are so many doctors prescribing them, surely it could save the nhs money if they just stuck to the normal coating...

I have always thought that these drugs also have a local irritant effect on the stomach, as well as the systemic effect. As well as enteric coating tablets, this can also be reduced by using the drug in another forrm - e.g. Diclofenac suppositories. I'm sure there must be studies to show that using e/c tabs, suppositories or even injections have less GI side effects then plain oral tablets.

[Zoggite]

Trust me, even diclofenac suppositories can give you stomach pains!
Maybe the e/c coating helps reduce irritation of the GI tract upstream of the stomach, i.e. the mouth, throat, & gullet; also coatings often mask the bitter taste of a tablet...
I don't think cost has anything to do with the formulation any more: why is omeprazole 20mg capsules so much cheaper that 10mg-capsules or 20mg-tablets?
While we're on the subject: has anyone else noticed the multiplication of scripts for aspirin 75mg dispersible, and on the same Rx omeprazole 20mg caps. "take one daily as on aspirin"? This leaves me very confused! What a back-to-front way of doing things!

[mm45]

yeah I have noticed this problem to. Just curious if you were able to influence prescribers what would you suggest to the aspirin 75mg Rx?

While I was working at a pharmacy, im only a student, I noticed a Rx for simvastatin 10mg two a day, I pointed out to the pharmacist that a Rx for 20mg once a day would be cheaper the pharmacist just said yeah and that was that. I just feel that even if we were to contact the prescriber and be taken seriously to suggest a change to 20mg once daily woud save the NHS money. Ok it would be huge amount of money but it would be a start.

[Zoggite]

Well, this is where those blessed MURs come in quite handy: not only do surgeries actually take notice of them (if you send the forms to their practice pharmacist), but you also get paid for doing so, the GPs get their QoF-points, AND the patient thinks you've actually done something for them! an all-round "win-win" situation!

[admin]

Trust me, even diclofenac suppositories can give you stomach pains!
Maybe the e/c coating helps reduce irritation of the GI tract upstream of the stomach, i.e. the mouth, throat, & gullet; also coatings often mask the bitter taste of a tablet...

I know systemic diclofenac can still cause stomach problems via the mechanism already mentioned, but my point is that the e/c tablets or the suppositories must cause less irritation?

You can just sugar coat a tablet to mask the taste - cheaper to do then e/c coating.

I understand all the strange pricings in the drug tariff, but to an individual company production time is very expensive, so they would always rather reduce this, and thus save on costs.

[admin]

yeah I have noticed this problem to. Just curious if you were able to influence prescribers what would you suggest to the aspirin 75mg Rx?

While I was working at a pharmacy, im only a student, I noticed a Rx for simvastatin 10mg two a day, I pointed out to the pharmacist that a Rx for 20mg once a day would be cheaper the pharmacist just said yeah and that was that. I just feel that even if we were to contact the prescriber and be taken seriously to suggest a change to 20mg once daily woud save the NHS money. Ok it would be huge amount of money but it would be a start.

I don't understand the pharmacist in this situation. I have contacted surgeries lots of times about statins, and they usually welcome any advice that saves THEIR budget - not the NHS. I find it's quite a good way to make first contact with them, as you are phoning up to save them money and not to just moan about something.

[johnep]

NSAIDs

MSD produced indocid in a coated tablet with a minute hole produced by laser. However, high local concentration if hole against stomach wall caused severe problems and product was dropped.
johnep

[Pharmanaut]

Osmosin

MSD produced indocid in a coated tablet with a minute hole produced by laser. However, high local concentration if hole against stomach wall caused severe problems and product was dropped.
johnep

I remember that - it was called Osmosin.

There might be two things at work with the NSAIDs, the direct effect and the systemic effect. The direct effect might be caused by a 'lump' of the drug being in one place in the stomach acting on the mucosa, whereas the systemic effect involves more even drug distribution. A lot of them are propionic acid derivatives, so the high pH of the stomach would make them less dissociated and relatively more able to pass through the stomach wall. Or something like that science stuff kind of thing...I suppose, maybe possibly.

[_Rob_]

Ah, good ol' EC aspirin/NSAIDs debate....

Well, there was some interesting research on this on so long ago which looked at incidence of GI irritation in plain vs EC aspirin. They did find that the patients on EC aspirin had a lower rate of GI related problems. Interestingly, the reasons they stated for this was a reduced bioavailability of EC aspirin. As somebody quite rightly pointed out earlier, NSAID GI irritation is cause by a systemic COX inhibition decreasing prostaglandin production and hence reduced gastric protection. That said, I feel sure remembering from my uni days, that aspirin (acetylsalicylic acid) crystals are ‘needle like’ (if looked at under an electron microscope) and have been blamed for making *very* small lacerations to the stomach lining.

In my hospital we swap everybody to plain aspirin – it’s a money thing!

[Zoggite]

In my hospital we swap everybody to plain aspirin – it’s a money thing!

That's fine, until the whole saving gets negated by the patient being p'bed omeprazole to protect his stomach...

[Cathedral]

About this diclofenac supp. - we've got a patient with horrible ulceration in anus area after very long use of these suppositories. And of course she had them prescribed because of "weak stomach".