Review of NSAID abuse in Belfast trust- a look at biochemistry, imaging and endoscopy.
Adgey C, Small S, Loughrey C, Rafferty G, Turner G
Belfast Trust, Northern Ireland
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and their associated upper Gastro-intestinal toxicity is well documented. Deliberate mis-use of NSAIDs (+/- codeine) is under -recognised, representing a significant disease profile and burden on healthcare resources. Literature analysis of NSAID abuse to date is limited predominantly to single and small case based publications. 1-7
This review focuses on biochemistry, imaging and endoscopic features associated with NSAID abuse in an identified patient cohort within Belfast Trust outlining their disease timeline from presentation to diagnosis.
Within the Belfast Trust the review population was identified from known NSAID-abusing patients. For each patient, demographic data was compiled with each subsequent admission reviewed to collate each patient’s imaging and blood profile from initial presentation and most abnormal, as well as endoscopy findings and pathology. The time-frame from first presentation of an NSAID-related problem to diagnosis was established as well as number and duration of admissions.
Fourteen patients were identified, 9 of whom were female (64.3%). Age range was 29-53yrs (mean 39.9). Each patient’s lightest weight was reviewed with figures available for 12 of 14 patients ranging from 27-54kg (median 45.5kg). Each patient’s biochemistry was assessed in 13 of14 cases, from initial presentation to most abnormal as outlined in the table below. Biochemistry at Initial Presentation and most abnormal results Initial presentation median (interquartile range) Most abnormal presentation median (interquartile range) P value Albumin 38 (31-42) 24 (15-32) 0.009 Haemoglobin 89 (83.5-112.75) 65 (61-71) P<0.001 CO2 21 (18-24) 11.5 (7-14) P<0.001 Potassium 3.6 (3.2-4.3) 2.3 (2-2.8) P<0.001 Creatinine 75 (60-92) 156 (88-229) 0.009 Time to diagnosis of NSAID abuse from initial presentation of NSAID-related complication was 0-72 months (median 15 months). All patients had peptic ulceration on at least one endoscopy, 6 had gastric outlet obstruction. The number of hospital admissions ranged from 1-26 (median 9). Bed days required ranged from 3-1088 (median 125 days).
The burden of disease associated with NSAID abuse spans hospital specialties and multi-disciplinary teams with recurrent and prolonged admissions. A characteristic profile of anaemia, hypoalbuminaemia, hypokalaemia and acidosis (renal tubular) with renal function impairment was identified. These abnormalities became more marked with continued NSAID abuse. Upper GI pathology and nutritional inadequacy were also seen as frequent complications. Greater awareness of these discriminating clinical, biochemical and endoscopic features amongst healthcare professionals may prompt NSAID abuse inclusion in differential diagnoses, preventing delays in diagnosis and management in the future.