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The relationship between nonsteroidal anti-inflammatory drug (NSAID) use and exacerbations of inflammatory bowel disease (IBD) may not be as clear-cut as previously thought, according to the results of a systematic review and meta-analysis.
The report was published online in Alimentary Pharmacology and Therapeutics.
The researchers presented their analysis of 18 studies examining the association between acetaminophen, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors, and the risk of Crohn’s disease, ulcerative colitis flares, and IBD.
Five studies looked at the association between NSAIDS – such as naproxen and indomethacin – and the risk of Crohn’s disease exacerbation. While this showed a 42% increased risk of exacerbation with NSAID use, the authors noted that they saw substantial heterogeneity across the studies.
For example, two nonrandomized trials comparing NSAIDs and acetaminophen in patients with quiescent disease found NSAIDs were associated with frequent, early clinical relapse of IBD. But another study comparing patients with symptom flares and those in clinical remission found no difference between the two groups in the frequency of NSAID use.
Researchers also conducted a meta-analysis of studies involving acetaminophen, which found a statistically significant 56% increase in the risk of IBD exacerbation with acetaminophen. However, in the systematic review, there were two nonrandomized clinical trials which showed only one disease exacerbation in 46 patients with quiescent IBD, which was lower than the rate seen in the NSAID group.
Given the heterogeneity seen across the studies, the authors conducted an analysis limited to studies that scored seven or above on the Newcastle-Ottowa Scale for assessing the quality of nonrandomized studies. In this analysis, the risk of Crohn’s disease exacerbations increased significantly with NSAID use (RR = 1.53; 95% confidence interval, 1.08-2.16) but they did not see an association between NSAID use and the risk of ulcerative colitis or other IBD exacerbations.
Similarly, when they restricted their analysis to studies with a low risk of bias, the researchers found there was an increased risk of Crohn’s disease exacerbations, but not ulcerative colitis, with NSAID use.
“American College of Gastroenterology guidelines for management of IBD recognise NSAIDs as potential triggers for disease exacerbation, highlighting the ongoing concern regarding the use of these medications in patients with established disease,” wrote Dr. Oluwatoba Moninuola of Harvard University T.H. Chan School of Public Health, and coauthors.
“Although, it’s well established that NSAIDs may cause de novo damage throughout the gastrointestinal tract, the precise mechanism through which NSAIDs promote IBD exacerbation remains largely unknown.”
They said previous research suggested COX-1 and COX-2 inhibitors may be responsible for the inhibition of intestinal prostaglandin synthesis.
The authors also noted that wide variations in the definition of disease exacerbation may have contributed to the heterogeneity of the studies included, and that there may have been confounding by the indication for acetaminophen and NSAID use.
“We recognise that IBD is a heterogeneous disease and therefore, there may be subgroups of patients particularly at risk of disease exacerbations with use of NSAIDs.”
One author was supported by the American Gastroenterological Association and by the National Institute of Diabetes and Digestive and Kidney Diseases, and declared consulting and research funding from the pharmaceutical industry. No other conflicts of interest were declared.
SOURCE: Moninuola O et al. Aliment Pharmacol Ther. 2018 Apr 5. doi: 10.1111/apt.14606.
The relationship between nonsteroidal anti-inflammatory drug (NSAID) use and exacerbations of inflammatory bowel disease (IBD) may not be as clear-cut as previously thought, according to the results of a systematic review and meta-analysis.
The report was published online in Alimentary Pharmacology and Therapeutics.
The researchers presented their analysis of 18 studies examining the association between acetaminophen, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors, and the risk of Crohn’s disease, ulcerative colitis flares, and IBD.
Five studies looked at the association between NSAIDS – such as naproxen and indomethacin – and the risk of Crohn’s disease exacerbation. While this showed a 42% increased risk of exacerbation with NSAID use, the authors noted that they saw substantial heterogeneity across the studies.
For example, two nonrandomized trials comparing NSAIDs and acetaminophen in patients with quiescent disease found NSAIDs were associated with frequent, early clinical relapse of IBD. But another study comparing patients with symptom flares and those in clinical remission found no difference between the two groups in the frequency of NSAID use.
Researchers also conducted a meta-analysis of studies involving acetaminophen, which found a statistically significant 56% increase in the risk of IBD exacerbation with acetaminophen. However, in the systematic review, there were two nonrandomized clinical trials which showed only one disease exacerbation in 46 patients with quiescent IBD, which was lower than the rate seen in the NSAID group.
Given the heterogeneity seen across the studies, the authors conducted an analysis limited to studies that scored seven or above on the Newcastle-Ottowa Scale for assessing the quality of nonrandomized studies. In this analysis, the risk of Crohn’s disease exacerbations increased significantly with NSAID use (RR = 1.53; 95% confidence interval, 1.08-2.16) but they did not see an association between NSAID use and the risk of ulcerative colitis or other IBD exacerbations.
Similarly, when they restricted their analysis to studies with a low risk of bias, the researchers found there was an increased risk of Crohn’s disease exacerbations, but not ulcerative colitis, with NSAID use.
“American College of Gastroenterology guidelines for management of IBD recognise NSAIDs as potential triggers for disease exacerbation, highlighting the ongoing concern regarding the use of these medications in patients with established disease,” wrote Dr. Oluwatoba Moninuola of Harvard University T.H. Chan School of Public Health, and coauthors.
“Although, it’s well established that NSAIDs may cause de novo damage throughout the gastrointestinal tract, the precise mechanism through which NSAIDs promote IBD exacerbation remains largely unknown.”
They said previous research suggested COX-1 and COX-2 inhibitors may be responsible for the inhibition of intestinal prostaglandin synthesis.
The authors also noted that wide variations in the definition of disease exacerbation may have contributed to the heterogeneity of the studies included, and that there may have been confounding by the indication for acetaminophen and NSAID use.
“We recognise that IBD is a heterogeneous disease and therefore, there may be subgroups of patients particularly at risk of disease exacerbations with use of NSAIDs.”
One author was supported by the American Gastroenterological Association and by the National Institute of Diabetes and Digestive and Kidney Diseases, and declared consulting and research funding from the pharmaceutical industry. No other conflicts of interest were declared.
SOURCE: Moninuola O et al. Aliment Pharmacol Ther. 2018 Apr 5. doi: 10.1111/apt.14606.
The relationship between nonsteroidal anti-inflammatory drug (NSAID) use and exacerbations of inflammatory bowel disease (IBD) may not be as clear-cut as previously thought, according to the results of a systematic review and meta-analysis.
The report was published online in Alimentary Pharmacology and Therapeutics.
The researchers presented their analysis of 18 studies examining the association between acetaminophen, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors, and the risk of Crohn’s disease, ulcerative colitis flares, and IBD.
Five studies looked at the association between NSAIDS – such as naproxen and indomethacin – and the risk of Crohn’s disease exacerbation. While this showed a 42% increased risk of exacerbation with NSAID use, the authors noted that they saw substantial heterogeneity across the studies.
For example, two nonrandomized trials comparing NSAIDs and acetaminophen in patients with quiescent disease found NSAIDs were associated with frequent, early clinical relapse of IBD. But another study comparing patients with symptom flares and those in clinical remission found no difference between the two groups in the frequency of NSAID use.
Researchers also conducted a meta-analysis of studies involving acetaminophen, which found a statistically significant 56% increase in the risk of IBD exacerbation with acetaminophen. However, in the systematic review, there were two nonrandomized clinical trials which showed only one disease exacerbation in 46 patients with quiescent IBD, which was lower than the rate seen in the NSAID group.
Given the heterogeneity seen across the studies, the authors conducted an analysis limited to studies that scored seven or above on the Newcastle-Ottowa Scale for assessing the quality of nonrandomized studies. In this analysis, the risk of Crohn’s disease exacerbations increased significantly with NSAID use (RR = 1.53; 95% confidence interval, 1.08-2.16) but they did not see an association between NSAID use and the risk of ulcerative colitis or other IBD exacerbations.
Similarly, when they restricted their analysis to studies with a low risk of bias, the researchers found there was an increased risk of Crohn’s disease exacerbations, but not ulcerative colitis, with NSAID use.
“American College of Gastroenterology guidelines for management of IBD recognise NSAIDs as potential triggers for disease exacerbation, highlighting the ongoing concern regarding the use of these medications in patients with established disease,” wrote Dr. Oluwatoba Moninuola of Harvard University T.H. Chan School of Public Health, and coauthors.
“Although, it’s well established that NSAIDs may cause de novo damage throughout the gastrointestinal tract, the precise mechanism through which NSAIDs promote IBD exacerbation remains largely unknown.”
They said previous research suggested COX-1 and COX-2 inhibitors may be responsible for the inhibition of intestinal prostaglandin synthesis.
The authors also noted that wide variations in the definition of disease exacerbation may have contributed to the heterogeneity of the studies included, and that there may have been confounding by the indication for acetaminophen and NSAID use.
“We recognise that IBD is a heterogeneous disease and therefore, there may be subgroups of patients particularly at risk of disease exacerbations with use of NSAIDs.”
One author was supported by the American Gastroenterological Association and by the National Institute of Diabetes and Digestive and Kidney Diseases, and declared consulting and research funding from the pharmaceutical industry. No other conflicts of interest were declared.
SOURCE: Moninuola O et al. Aliment Pharmacol Ther. 2018 Apr 5. doi: 10.1111/apt.14606.
FROM ALIMENTARY PHARMACOLOGY AND THERAPEUTICS
Key clinical point: Nonsteroidal anti-inflammatory drugs may increase the risk of some inflammatory bowel diseases.
Major finding: NSAIDs are associated with a 42% increased risk of Crohn’s disease exacerbation.
Study details: Systematic review and meta-analysis of 18 studies.
Disclosures: One author was supported by the American Gastroenterological Association and by the National Institute of Diabetes and Digestive and Kidney Diseases, and declared consulting and research funding from the pharmaceutical industry. No other conflicts of interest were declared.
Source: Moninuola O et al. Aliment Pharmacol Ther. 2018 Apr 5. doi: 10.1111/apt.14606.