NSAID and Acetaminophen and Diverticular Disease
ABSTRACT & COMMENTARY
Synopsis: This study indicates that the use of acetaminophen and NSAIDs is associated with severe diverticular disease, especially bleeding.
Source: Aldoori, et al. Arch Fam Med 1998;7:255-260.
Almost 33% percent of patients over age 45 and 67% over age 85 have diverticular disease. There are frequently no symptoms; less than one-fourth of the patients develop symptomatology. This still results in almost 250,000 hospitalizations in the United States annually.
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen in this patient population is significantly high. The association of these products with diverticular disease was a distinct possibility, but this association had not been studied previously.
Aldoori et al conducted a rather simple prospective study. They first mailed a questionnaire to 35, 000 male health professionals (dentists, optometrists, veterinarians, physicians, pharmacists, osteopathic physicians, and podiatrists). They then followed the development of diverticular disease over time. The authors were able to show, after correcting for age, physical activity, and energy-adjusted dietary fiber and fat intake, that the use of NSAIDs and acetaminophen was positively associated with the development of diverticular disease of a symptomatic variety.
By sophisticated statistical techniques they were able to develop relative risks. Subjects taking NSAIDs had a 2.24 times higher risk in the development of diverticular disease, while those taking acetaminophen had a 1.81 times greater risk. Of interest was that these drugs seemed to have more of a positive association in diverticular disease patients that developed bleeding.
COMMENT BY LEN SCARPINATO, DO
Diverticular disease continues to be the occult diagnosis for me when I teach residents about abdominal pain in hospitalized patients. The NSAIDs and acetaminophen are used significantly in the elderly population for all the aches and pains that come with getting old (at 41, I am beginning to feel some of these myself). Wouldn't it be scary if these drugs had a relationship with this disease?
If you think about it, it is not too far-fetched. Nonsteroidals have been associated with the development of upper GI bleeding. In Aldoori et al's study, we see that there is actual association. The fact that there isn't a dose response curve is commented on in an editorial by James W. Mold, MD, in the same issue. It would be a more powerful study if there had been a dose response curve. There may actually be a threshold of NSAIDs and acetaminophen beyond which bleeding and diverticular disease become risks.
If someone has asymptomatic diverticular disease, does it matter whether they take NSAIDs and acetaminophen? Aldoori et al's study makes one wonder: Is it causative?
Most surprising about Aldoori et al's study is the almost equivalent risk of taking acetaminophen. We have all been reassuring our patients that acetaminophen has no effects when it comes to the GI tract. I believe we will have to be a little more cautious in the future about saying this, especially when it relates to diverticular disease.
Now, when I tell a patient who has some aches and pains to take an NSAID or acetaminophen, I will have to remind them that, if they have asymptomatic diverticular disease, it may put them at high risk for a bleeding problem.
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