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Am Fam Physician. 2001;63(4):637-638

to the editor: When will we ever learn? Physicians, patients and society have become so used to over-the-counter and prescription non-steroidal anti-inflammatory drugs (NSAIDs) as an everyday fact of life that we have become numbed to the devastation they cause. In “Cyclooxygenase-2 Enzyme Inhibitors: Place in Therapy,”1 the authors, in an otherwise excellent article, state: “Although generally safe, ‘traditional’ NSAIDs account for almost one fourth of all reported adverse drug events. Approximately 15 percent of NSAID users have gastrointestinal tract symptoms such as dyspepsia, heartburn, nausea or vomiting. Each year, 1 to 4 percent of NSAID users have serious gastrointestinal tract complications such as hemorrhage, with an estimated cost of $15,000 to $20,000 per hospitalization. An estimated 16,500 NSAID-related deaths occur annually among patients with osteoarthritis or rheumatoid arthritis. Medical costs of complications associated with NSAID use exceed $4 billion annually.”1

Since when are 16,500 deaths, $4 billion dollars in complications and a 15 percent rate of gastrointestinal complications including gastrointestinal hemorrhage and other debilitating and potentially lethal side effects considered “generally safe”? The authors did not mention renal, liver and other associated toxicities.

It's time we think of these medications as the dangerous and potentially lethal drugs they are. When we supervise a resident who casually prescribes ibuprofen to an elderly patient or when we ourselves feel pressed to find an easy answer to a throbbing back or head pain in a hypertensive patient we should think “danger” not “generally safe.”

in reply :Dr. Rosen makes an excellent point. Perhaps the word “considered” should be inserted between the words “generally” and “safe.” This article1 tried to convey the significance of adverse events due to NSAID therapy by presenting the startling facts of NSAID-induced morbidity and mortality in that same paragraph.

In an earlier version of the article, the abstract did contain the sentence “NSAIDs can also adversely influence blood pressure control, the central nervous system, and cause renal complications.” As the article went through medical and copy editing, this sentence was deleted. It was felt that family physicians are aware of the common adverse effects that NSAID therapy may cause. I appreciate your concern and would like to echo that NSAID therapy, although generally considered safe, indeed is not without significant risks.

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