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Original Research (Original Article) 


Omar Ahmed Asiri et al, 2020;4(2):296–302.

International Journal of Medicine in Developing Countries

Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study

Omar Ahmed Asiri1*, Asim Ali Alzahrani1, Khalid Mohammed Alshehri1, Othman Waslallah Althomal1, Abdulmohsen Abdulaziz Islam Alameen1, Mohamed Abdelhamid Serwah2

Correspondence to: Omar Ahmed Asiri

*Medical Intern, College of Medicine, Taif University, Taif, Saudi Arabia.

Email: Dr.omarasiri [at] gmail.com

Full list of author information is available at the end of the article.

Received: 16 October 2019 | Accepted: 03 January 2019


ABSTRACT

Background:

The prevalence of gastrointestinal injuries resulting from the widespread use of non-steroidal anti-inflammatory drugs (NSAIDs) is not uncommon. This study aims to assess the prevalence of NSAIDs usage and to assess the knowledge and attitude regarding gastrointestinal diseases and complications related to its usage.


Methodology:

A cross-sectional study was conducted using a pretested questionnaire that was used to collect the information related to the NSAIDs use, the prevalence of its complications, knowledge, and attitude related to its use and complications. A sample size of 547 was included with no gender discrimination. The data collected were analyzed using Statistical Package for the Social Sciences version 23.


Results:

About 65.1% of the participants agreed that they have taken NSAIDs in any form with 6.7% of them taking it regularly. The frequency of taking NSAIDs without a medical prescription was found to be 45.5%. Heartburn (46.6%) was a common complication related to NSAIDs usage followed by peptic ulcer diseases (45.2%). The commonly consumed NSAID was Ibuprofen (45.2%).


Conclusion:

The knowledge related to NSAIDs use and its complication was not satisfactory. There is a need to create awareness regarding the proper and safe use of NSAIDs that minimize the discomfort or complications related to its use and abuse.


Keywords:

NSAIDs, pain, complications, Saudi Arabia, gastrointestinal injury.


Introduction

The use of non-steroidal anti-inflammatory drugs (NSAIDs) has greatly increased over the past three decades in both developed and developing countries. NSAIDs have several side effects on different body systems with the gastrointestinal being the most important of them. The knowledge and awareness regarding the risk factors for gastrointestinal injuries are one of the most important methods to prevent a lot of complications, such as gastrointestinal bleeding and Barrett’s esophagus [1].

Studies have shown that the chronic and excessive use of NSAIDs is an important cause of gastrointestinal (GI) morbidity and mortality [2,3]. The death rates from excessive use of NSAIDs are increasing due to the magnitude of the random and non-organized use. Another problem with the NSAIDs is that these are the commonly prescribed medication for pain management with 67% of patients reporting having used them without a prescription, thus making the patients aware about their side effects is the only regulatory method [4]. A study conducted in Saudi Arabia reported that very fewer people are aware that NSAIDs are a risk factor for gastric irritation and gastric ulcer [5].

Gastroesophageal reflux disease (GERD) is one of the most common chronic digestive disorders and the prevalence of GERD was reported to be as high as 20% in the Western world at a much lower rate in Asia [6,7]. A meta-analysis done in 2007 shows a trend toward a higher prevalence of GERD in studies conducted more recently [8]. A study done by Altwigry et al. in Saudi Arabia reported a prevalence of GERD symptoms of 58% in high school teachers [9]. Another study that was done in the kingdom itself reported that the prevalence of GERD was 23.8% and the majority did not believe that GERD could cause dysphagia and odynophagia [10]. In response to these data, we decided to conduct this research to evaluate the current level of knowledge of the Taif city population about the possible GI injuries due to NSAIDs and gastroesophageal reflux disease.


Subjects and Methods

A cross-sectional study was conducted using a pre-tested and self-administered questionnaire from the 1st January 2019 to the 1st April 2019 on the general population of Taif city, Saudi Arabia. Taif city is located in Mecca Province in the west of Saudi Arabia in an elevation of 1,700 m on the slopes of the Al-Sarawat Mountains. It has a population of 987,914 (2010 census). We calculated a minimum sample of 483 and we included a total of 547 participants for our study.

The questionnaire included three sections; the first one contained the demographical data including age, gender, nationality, and level of education. The second one included questions regarding the usage of NSAIDs, such as if it is prescribed by a doctor or not, the reason for using them, and the type of NSAIDs with a picture of the medication package to aid the accuracy of selection. The third section was related to the prevalence of GERD symptoms and the knowledge of its complications and effects. Our questionnaire was tested for validity and reliability using a pilot study done in 30 subjects. The validity was tested and approved by three experts in the field and some modifications were done. The reliability measurement showed a Cronbach’s alpha value, r = 0.876. Trained medical students were given the responsibility to collect data through interviews using a questionnaire. Samples were recruited from shopping malls, hospitals, primary health care centers, universities, and schools. Before data collection, all participants have been informed about the nature of the study and their voluntary participation.

The collected data were entered by an expert and tabulated using software MS Excel. Statistical Analysis was carried out using Statistical Package for the Social Sciences version 23. Descriptive statistics, using frequencies and percentages, were done for continuous data. Pearson’s Chi-square test was used for finding any statistical relationship between categorical variables. A significance value (α) and p < 0.05 were considered to be statistically significant, and the power of the test (β) was set at 80% with a confidence interval of 95%.


Results

The analysis of our data showed that 32% were males and 68% were females. The mean age of the participants was 21.4 ± 12.3 years, with a minimum age of 18 and a maximum age of 68. The majority of the participants were Saudi Nationals (528) (96.5%) and only 19 (3.5%) participants were from other nationalities. When the educational qualification was assessed 63.8% of participants had a college education, 27.2% had a high school education, 3.8% had secondary school education, and 3.8% had primary school education. 2.7% of participants were post-graduates and only 0.4% were illiterate (Table 1).

The prevalence of using NSAIDS, the possible reasons for using them, the prevalence of having some of its complications, the most common type used of NSAIDs, and the participant’s knowledge of its complications are given in Table 2. Among the participants, 65.1% (n = 356) agreed that they had taken NSAIDs and 9.7% reported that they took it regularly. Out of 356 participants who agreed they have taken NSAIDs, 45.5% (n = 162) reported that they took it without any prescription (Table 2). When the relationship of the education of participants with NSAID usage was assessed, there was no statistically significant relationship observed, p > 0.05 (Table 3). There was also no significant association observed between NSAIDs usage without prescription and gender, p > 0.05 (Table 4).

Table 1. Socio-demographic details of the participants.

Frequency (N) Percent (%)
Gender Male 175 32
Female 372 68
Total 547 100
Nationality Saudi 528 96.5
Other nationalities 19 3.5
Total 547 100
Education Illiterate 2 0.4
Primary 11 2
Secondary 21 3.8
High school 149 27.2
Collage 349 63.8
Post-graduate 15 2.7
Total 547 100

Table 2. Distribution according to prevalence NSAID usage and related factors (n = 356).

Frequency (N) Percent (%)
Do you take it without a prescription? Yes 162 45.5
Nos 194 54.5
Total 356 100.0
The common reason for use NSAID Pain 110 30.9
Fever 126 35.4
Period 46 12.9
Headache 68 19.1
Insomnia 6 1.7
Total 356 100.0
How many tablets of NSAIDS do you take (per week)? 1–3 52 14.6
3–10 18 5.1
10 or more 2 .6
Only if needed 284 79.8
Total 356 100.0
Have you experienced any discomfort or problem due to NSAID usage? PUD 161 45.2
Heartburn 166 46.6
Stomachache 14 3.9
Indigestion 15 4.2
Total 356 100.0
Which type of NSAID do you take commonly? Aspirin 106 29.8
Ibuprofen 161 45.2
Naproxen 16 4.5
Celecoxib 73 20.5
Total 356 100.0

Table 3. Relationship of education on NSAID usage.

Do you take it without a prescription? Total Chi-square value p value
Yes No
Education Illiterate 2 0 2 7.7520 0.170
Primary 4 6 10
Secondary 9 5 14
High school 43 46 89
Graduate 103 131 234
Postgraduate 1 6 7
Total 162 194 356

Table 4. Relationship of gender with NSAID usage.

Do you take it without a prescription? Total Chi-square value p value
Yes No
Sex Male 52 72 124 0.978 0.323
Female 110 122 232
Total 162 194 356

The common reason for NSAID usage in these participants was fever (35.4%), followed by pain (30.9%). It was observed that 14.6% of participants took 1–3 tablets for one or other use weekly. The most common complication as reported by the participants due to NSAID usage was heartburn (46.6%), followed by peptic ulcer disease (PUD) (45.2%). Among the participants, 45.2% reported that they took Ibuprofen followed by Aspirin (29.8%) (Table 2). When the relationship between the type of NSAID and type of complication was assessed, there was no statistically significant relationship noted, p > 0.05 (Table 5).

When the knowledge related to NSAIDs usage, its complications and treatment were assessed, it was found that 96.5% (n = 528) of participants agreed that NSAIDs could be taken before or with meals. Among the participants, 36.9% (n = 202) believed that it could cause peptic ulcer diseases or bleeding (PUD). It was surprising to note that 70% believed that it could cause cancer and 38% believed that it could cause some pain. Among the participants, 87.6% believed that diet has a key role in the treatment of these complications due to NSAIDs usage. Only 12.6% of the participants agreed that they read about the side effects of the drugs they used (Table 6).


Discussion

NSAIDs including low dose aspirin are one of the commonly used drugs for symptomatic treatment of acute pain, headache, period pain, and inflammatory joint diseases due to its long clinical history, good efficacy, and also popularity [11]. The high prevalence of its usage has contributed to upper GI complications, such as peptic ulcers and bleeding, which may be predisposed to malignancies and this explains why its use should be restricted by promoting awareness among people about its side effects and complications [12]. The findings of our study show that 65% of our study population used NSAIDs, which makes it clear of its easy availability and accessibility. The percentage of participants who take NSAIDs without a doctor’s prescription is also more in our study, which indicates an easygoing attitude regarding its usage. Our study showed that Ibuprofen is the most frequently consumed drug that concurs with another study, which reported that it is the most frequently prescribed drug in Saudi Arabia [13]. Another study from the Kingdom of Saudi Arabia shows that Diclofenac is the most commonly used drug from all classes of drugs [14].

Table 5. Relationship of type of NSAID and type of complication.

Did you ever had any of these complications Total Chi-square value p-value
PUD Heartburn Stomachache Indigestion
Which type of NSAID do you take? Aspirin 55 41 7 3 106 14.526 0.104
Ibuprofen 64 85 7 5 161
Naproxen 7 8 0 1 16
Celecoxib 35 32 0 6 73
Total 161 166 14 15 356

Table 6. Knowledge and attitude related to NSAIDs usage, its complications, and treatment (n = 547).

Frequency (N) Percent (%)
NSAIDs can be taken before or with meals? Yes 528 96.5
No 19 3.5
Total 547 100.0
Do you think NSAIDs can cause any disease? Yes 529 96.7
No 18 3.3
Total 547 100.0
Can it cause peptic ulcer diseases – bleeding? Yes 202 36.9
No 345 63.1
Total 547 100.0
Do you believe that peptic ulcers cause cancer? Yes 383 70.0
No 164 30.0
Total 547 100.0
Can it cause pain? Yes 208 38.0
No 175 32.0
Don’t know 164 30.0
Total 547 100.0
Can it cause dysphagia? Yes 36 6.6
No 77 14.1
Don’t know 434 79.3
Total 547 100.0
Can it cause bleeding? Yes 203 37.1
No 180 32.9
Don’t know 164 30.0
Total 547 100.0
Do you think it can be treated? Yes 493 90.1
No 54 9.9
Total 547 100.0
Do you think diet has any role to treat it? Yes 479 87.6
No 68 12.4
Total 547 100.0
What is the most useful treatment? Diet 471 86.1
Medication 76 13.9
Total 547 100.0
Can NSAID use cause ulcers? Yes 463 84.6
No 84 15.4
Total 547 100.0
Do you think it could lead to surgery? Yes 507 92.7
No 40 7.3
Total 547 100.0
Do you think there is a limit to the amount you can take? Yes 530 96.9
No 17 3.1
Total 547 100.0
Do you need a prescription to take NSAIDs? Yes 459 83.9
No 88 16.1
Total 547 100.0

In our study heartburn was the most commonly present complication among the participants due to NSAIDs usage. We cannot conclude that this is due to NSAIDs usage itself as it could be caused due to other factors also [15]. However, this finding gives us a hint that some of the participants are aware that NSAIDs usage could cause heartburn. Heartburn is caused due to acid reflux in patients, especially in patients with esophagitis [15]. Prolonged exposure of the esophagus to acid and digestive enzymes found in the stomach, or to the duodenal content (bile salts), may irritate and result in symptoms of Gastroesophageal Reflux Disease (GERD) and morphological changes in the esophagus [16]. The findings show that 96% of participants complained of symptoms of GERD and 98% of them reported an incident of these symptoms (heartburn-acid taste) waking them up from sleep. We also found out that 83% of the participants are not aware of the different complications related to the use of NSAIDs. The majority of the participants believed that NSAIDs do not cause any peptic ulcer diseases. Inhibition of COX-1 isoenzymes in the GI tract leading to reduced secretion of prostaglandin is the primary cause of peptic ulcer in NSAIDs, especially with non-selective COX inhibitors. The cyclo-oxygenase [COX]-2 selective inhibitors, such as Celecoxib, Meloxicam, have shown a much lower risk of gastrointestinal side effects than non-selective NSAIDs [17].

Nearly, 70% of the participants believe that peptic ulcers may cause cancer. However, the reason for this belief was not enquired. Gastrointestinal (GI) cancers resulting from a peptic ulcer cannot completely be associated with side effects from NSAIDs, as the reason for this is controversial. The leading cause of GI malignancies can be attributed to Helicobacter pylori (H. pylori) infections, alcohol consumption, smoking, etc. [18,19]. Studies report that NSAIDs, especially non-selective COX inhibitors, increase the risk of peptic ulcer [20], but the risk of gastric and colorectal cancer is found to be less with these drugs [21,22].

An esophageal stricture refers to the abnormal narrowing of the esophageal lumen, which is often associated with difficulty in swallowing (dysphagia) or painful swallowing [23]. This happens due to excessive fibrosis after the irritation to the esophagus and it is found in approximately 16% of the GERD patients [24]. The data in this study also indicated that there is a high frequency of NSAIDs consumption, which may lead to an overdose in these people.

The results of our study show that knowledge related to NSAIDs usage and its complications is poor among the participants. There is an urgent need to educate the public regarding the consumption of these drugs for a variety of reasons. The citizen should be made aware of other alternative drugs that have comparatively fewer side effects than commonly used drugs. Physicians should play a crucial role in educating patients on drug consumption and its related use. The community pharmacists have the responsibility of giving advice when dispensing the medications to patients who are buying without a doctor’s advice.


Conclusion

The knowledge related to NSAIDs’ consumption and its complications was not that satisfactory. Ibuprofen was the most frequently consumed analgesic. The prevalence of GERD was very high in these participants. There is an urgent need to educate and make awareness among the public regarding the proper usage of NSAIDs.


Acknowledgment

The authors gratefully acknowledge the support provided by the officials of Taif University and malls, hospitals, primary health care centers, and schools for facilitating the administrative aspects of this research and allowing the data collection. All participants deserve special thanks for their cooperation.


List of Abbreviations

NSAID Non-steroidal anti-inflammatory drugs
PUD Peptic ulcer disease

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The research has been approved by the Ethics Committee at Taif University on the 30th of April 2019 with the application number: 40-36-0162.


Author details

Omar Ahmed Asiri1, Asim Ali Alzahrani1, Khalid Mohammed Alshehri1, Othman Waslallah Althomal1, Abdulmohsen Abdulaziz Islam Alameen1, Mohamed Abdelhamid Serwah2

  1. Medical Intern, College of Medicine, Taif University, Taif, Saudi Arabia
  2. Associate Professor, Department of Medicine, College of Medicine, Taif University, Taif, Saudi Arabia

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How to Cite this Article
Pubmed Style

Asiri OA, Alzahrani AA, Alshehri KM, Althomali OW, Alameen AAI, Serwah MA. Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. IJMDC. 2020; 4(2): 296-302. doi:10.24911/IJMDC.51-1571228702


Web Style

Asiri OA, Alzahrani AA, Alshehri KM, Althomali OW, Alameen AAI, Serwah MA. Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. https://www.ijmdc.com/?mno=69833 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1571228702


AMA (American Medical Association) Style

Asiri OA, Alzahrani AA, Alshehri KM, Althomali OW, Alameen AAI, Serwah MA. Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. IJMDC. 2020; 4(2): 296-302. doi:10.24911/IJMDC.51-1571228702



Vancouver/ICMJE Style

Asiri OA, Alzahrani AA, Alshehri KM, Althomali OW, Alameen AAI, Serwah MA. Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. IJMDC. (2020), [cited October 15, 2021]; 4(2): 296-302. doi:10.24911/IJMDC.51-1571228702



Harvard Style

Asiri, O. A., Alzahrani, . A. A., Alshehri, . K. M., Althomali, . O. W., Alameen, . A. A. I. & Serwah, . M. A. (2020) Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. IJMDC, 4 (2), 296-302. doi:10.24911/IJMDC.51-1571228702



Turabian Style

Asiri, Omar Ahmed, Asim Ali Alzahrani, Khalid Mohammed Alshehri, Othman Waslallah Althomali, Abdulmohsen Abdulaziz Islam Alameen, and Mohamed Abdelhamid Serwah. 2020. Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. International Journal of Medicine in Developing Countries, 4 (2), 296-302. doi:10.24911/IJMDC.51-1571228702



Chicago Style

Asiri, Omar Ahmed, Asim Ali Alzahrani, Khalid Mohammed Alshehri, Othman Waslallah Althomali, Abdulmohsen Abdulaziz Islam Alameen, and Mohamed Abdelhamid Serwah. "Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study." International Journal of Medicine in Developing Countries 4 (2020), 296-302. doi:10.24911/IJMDC.51-1571228702



MLA (The Modern Language Association) Style

Asiri, Omar Ahmed, Asim Ali Alzahrani, Khalid Mohammed Alshehri, Othman Waslallah Althomali, Abdulmohsen Abdulaziz Islam Alameen, and Mohamed Abdelhamid Serwah. "Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study." International Journal of Medicine in Developing Countries 4.2 (2020), 296-302. Print. doi:10.24911/IJMDC.51-1571228702



APA (American Psychological Association) Style

Asiri, O. A., Alzahrani, . A. A., Alshehri, . K. M., Althomali, . O. W., Alameen, . A. A. I. & Serwah, . M. A. (2020) Prevalence of non-steroidal anti-inflammatory drugs usage and assessment of knowledge related to its complications among Saudi population; a cross-sectional study. International Journal of Medicine in Developing Countries, 4 (2), 296-302. doi:10.24911/IJMDC.51-1571228702