Non-steroidal anti-inflammatory drugs and peptic ulcers.

Abstract

department of our hospital attend because of musculoskeletal complaints and injuries. A glance at the journals of the defence organisations reveals that such injuries are often a fruitful source of litigation. We hope that the omission oforthopaedic surgery is an error in the construction of the questionnaire used in the study rather than a reflection on its lack of teaching. (1) They could offer a merit award in advance of it being given through the national system. Such awards would be for a fixed term and renewable.(2) They could, as now, offer particular help with removal expenses.(3) They could, as now, offer such inducements as laboratory space, technical or secretarial help, equipment, or other appropriate attractions.These proposals change the present position very little and maintain the structure of national pay scales. They do, however, leave self governing trusts enough flexibility to enable them to attract talented individuals, whether to academic or to NHS posts.Guy's Hospital, London S I OR'T Non-steroidal anti-inflammatory drugs and peptic ulcers SIR,-Dr C J Hawkey's review on non-steroidal anti-inflammatory drugs and peptic ulcers' was exhaustive in all but one respect.In his section on prophylaxis he refers to the total cost of coprescribing either H2 receptor antagonists or prostaglandin analogues and states that the cost per life saved by coprescribing would be about £3 million. The point that he seems to miss is that the coprescription of antiulcer drugs with non-steroidal anti-inflammatory drugs can still be cost effective despite this very high figure. Cost per life saved is only one end point in a formal economic evaluation of a treatment.Non-steroidal anti-inflammatory drugs cause morbidity as well as death. Complications such as perforation, gastrointestinal haemorrhage, and ulceration are more common than death and are discussed in detail by Dr Hawkey, but their costs are not. All of the complications of non-steroidal anti-inflammatory drugs have direct, indirect, and intangible costs. The direct costs relate to hospitalisation and inpatient and outpatient care; the indirect costs relate primarily to absenteeism from work; and the intangible costs relate to quality of life measures such as pain, anxiety, and immobility.Referrals to hospital for complications associated with non-steroidal drugs may well be the tip of the iceberg. Most patients with more trivial adverse reactions may seek help from their general practitioners or pharmacists or not seek any medical help. This morbidity may, however, be important and should not be discounted.Another facet of coprescribing is also omitted. A high proportion of patients are intolerant to non-steroidal anti-inflammatory drugs,2 with up to 60% of patients who take them reporting dyspepsia.' Studies with H2 receptor antagonists have shown that coprescription with non-steroidal anti-inflammatory drugs significantly reduces gastric intolerance and allows patients to continue taking non-steroidal drugs.4The use of economic evaluation may also be u...