BackgroundThe use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with serious adverse drug events (ADEs). AimTo determine the prevalence of over-thecounter (OTC) NSAID use in the general population and in patients with a high risk of developing a serious NSAID-related ADE. Design and settingCross-sectional study in four general practices in the Netherlands. MethodTwo patient samples were selected: a random sample of adults (general population sample); and adult patients with a high risk of developing a serious ADE in case of NSAID use (highrisk sample). All included patients were sent a questionnaire regarding their use of OTC NSAIDs in the 4 weeks prior to participation. ResultsIn the general population sample, 118 of 456 (26%) invited patients completed the questionnaire. Of these, 35 (30%) had used an OTC NSAID. In the high-risk sample, 264 of 713 (37%) invited patients completed the questionnaire, and of these high-risk patients 33 (13%) had used an OTC NSAID. Over 20% of OTC NSAID users in the general population sample and over 30% in the high-risk sample had used the OTC NSAID for >7 days. OTC NSAIDs were used in a dosage exceeding the recommended daily maximum by 9% and 3% of OTC NSAID users in the general population and the high-risk sample respectively. ConclusionOTC NSAIDs are used by almost one-third of the general population. In the high-risk patients selected, one in eight patients used an OTC NSAID. Continued efforts by health authorities and healthcare professionals to inform patients of the risks of these drugs are warranted. Keywordsanti-inflammatory agents, non-steroidal; general practice; over-the-counter drugs; primary care. 20-21 Study populationWithin the participating practices, two samples of patients were selected, using the medical records contained in the IPCI database. The first was a random sample of all adult patients aged ≥18 years (general population sample). In the second sample adult patients were specifically selected who, according to Dutch clinical prescription guidelines, 7,10-12 had at least one risk factor leading to a high risk of developing a serious NSAID-related ADE (high-risk sample). It was aimed to select at least the following number of patients from each of the following risk groups:• 150 patients with a history of peptic ulcer or ulcer complication;• 200 patients aged >70 years;• 300 patients with two or more of the following minor risk factors: use of anticoagulant, use of aspirin, use of corticosteroid, use of selective serotonin reuptake inhibitor, age 60-70 years, history of severe rheumatoid arthritis, diabetes mellitus or heart failure;• 50 patients with a history of myocardial infarction;• 50 patients with a history of stroke;• 100 patients with a history of heart failure; or• 50 patients with a glomerular filtration rate (GFR) <30mL/min.As these risk factors often overlap, patients could be selected more than once, thereby contributing to the numbers in each risk group. The diagnoses of diseases and conditions mentioned were ide...

The relative frequency of different diagnoses among diabetic and non-diabetic patients attending a memory clinic was similar, indicating that diabetes does not predispose to one particular subtype of dementia. The imaging findings support the notion that the increased risk of cognitive decline and dementia in elderly subjects with diabetes is due to dual pathology, involving both cerebrovascular disease and cortical atrophy.

AIMSLow-dose aspirin (LDA) and non-steroidal-anti-inflammatory drugs (NSAIDs) both increase the risk of upper gastrointestinal events (UGIEs). In the Netherlands, recommendations regarding the prescription of gastroprotective agents (GPAs) in LDA users were first issued in 2009 in the HARM-Wrestling consensus. National guidelines on gastroprotective strategies (GPSs) in NSAID users were issued in the first part of the preceding. The aim of the present study was to examine time-trends in GPSs in patients initiating LDA and those initiating NSAIDs between 2000 and 2012. METHODSWithin a large electronic primary healthcare database, two cohorts were selected: (i) patients newly prescribed LDA and (ii) patients newly prescribed NSAIDs between 2000 and 2012. Patients who had been prescribed a GPA in the previous six months were excluded. For both cohorts, patients' risk of a UGIE was classified as low, moderate or high, based on the HARM-Wrestling consensus, and the presence of an adequate GPSwas determined. RESULTSA total of 37 578 patients were included in the LDA cohort and 352 025 patients in the NSAID cohort. In both cohorts, an increase in GPSs was observed over time, but prescription of GPAs was lower in the LDA cohort. By 2012, an adequate GPS was present in 31.8% of high-risk LDA initiators, vs. 48.0% of high-risk NSAID initiators. CONCLUSIONSDespite a comparable risk of UGIEs, GPSs are prescribed less in high-risk LDA initiators than in high-risk NSAID initiators. For both groups of patients, there is still room for improvement in guideline adherence. WHAT IS KNOWN ABOUT THIS SUBJECT• Low-dose aspirin and NSAIDs both increase the risk of serious upper gastrointestinal events. This risk can be reduced by concomitant prescription of a gastroprotective agent.• Various national and international guidelines have been issued regarding gastroprotective strategies in high-risk NSAID users, but recommendations on the prescription of gastroprotective agents in low-dose aspirin users were not issued until more recently. WHAT THIS STUDY ADDS• This study shows that the prescription of gastroprotective agents is far lower in high-risk lowdose aspirin users than in high-risk NSAID users, despite a comparable risk of upper gastrointestinal events in these high-risk groups. Less familiarity with the recommendations for low-dose aspirin users may play a role. However, even for NSAID users there is room for improvement in guideline adherence.• Of the environmental factors investigated, a change in the reimbursement policy of proton pump inhibitors had the clearest visible effect on prescription of gastroprotective agents in both low-dose aspirin and NSAID users, demonstrating the influence of such policy measures on guideline adherence.

Objective. To determine the influence of ischaemic cardiovascular (CV) risk on prescription of non-steroidal anti-inflammatory drugs (NSAIDs) by general practitioners (GPs) in patients with musculoskeletal complaints. Design. Cohort study. Setting. A healthcare database containing the electronic GP medical records of over one million patients throughout the Netherlands. Patients. A total of 474 201 adults consulting their GP with a new musculoskeletal complaint between 2000 and 2010. Patients were considered at high CV risk if they had a history of myocardial infarction, angina pectoris, stroke, transient ischaemic attack, or peripheral arterial disease, and at low CV risk if they had no CV risk factors. Main outcome measures. Frequency of prescription of non-selective (ns)NSAIDs and selective cyclooxygenase-2 inhibitors (coxibs). Results. Overall, 24.4% of patients were prescribed an nsNSAID and 1.4% a coxib. Of the 41,483 patients with a high CV risk, 19.9% received an nsNSAID and 2.2% a coxib. These patients were more likely to be prescribed a coxib than patients with a low CV risk (OR 1.9, 95% CI 1.8–2.0). Prescription of nsNSAIDs decreased over time in all risk groups and was lower in patients with a high CV risk than in patients with a low CV risk (OR 0.8, 95% CI 0.7–0.8). Conclusion. Overall, patients with a high CV risk were less likely to be prescribed an NSAID for musculoskeletal complaints than patients with a low CV risk. Nevertheless, one in five high CV risk patients received an NSAID, indicating that there is still room for improvement.

Objective. To determine how often patients with musculoskeletal (MSK) complaints prescribed a non-steroidal anti-inflammatory drug (NSAID) subsequently consult their general practitioner (GP) with a non-serious adverse drug reaction (ADR). Design. Cohort study. Setting. A healthcare database containing the electronic GP medical records of over 1.5 million patients throughout the Netherlands. Patients. A total of 16 626 adult patients with MSK complaints prescribed an NSAID. Main outcome measures. The patients’ medical records were manually assessed for the duration of NSAID use for a maximum of two months, and consultations for complaints predefined as potential ADRs were identified. Subsequently, the likelihood of an association with the NSAID use was assessed and these potential ADRs were categorized as likely, possible, or unlikely ADRs. Results. In total, 961 patients (6%) consulted their GP with 1227 non-serious potential ADRs. In 174 patients (1%) at least one of these was categorized as a likely ADR, and in a further 408 patients (2.5%) at least one was categorized as a possible ADR. Dyspepsia was the most frequent likely ADR, followed by diarrhoea and dyspnoea (respectively 34%, 8%, and 8% of all likely ADRs). Conclusion. Of the patients with MSK complaints prescribed an NSAID, almost one in 30 patients re-consulted their GP with a complaint likely or possibly associated with the use of this drug. The burden of such consultations for non-serious ADRs should be taken into account by GPs when deciding whether treatment with an NSAID is appropriate.