Gastrointestinal Safety of Cyclooxygenase-2 Inhibitors: A Cochrane Collaboration Systematic Review

Rostom, Alaa; Muir, Katherine; Dubé, Catherine; Jolicoeur, Emilie; Boucher, Michel; Joyce, Janet; Tugwell, Peter; Wells, George

doi:10.1016/j.cgh.2007.03.011

Cited by 223 publications

(145 citation statements)

References 78 publications

Supporting

Mentioning

130

Contrasting

Unclassified

Order By: Relevance

“…Randomized trials in NSAID users show that co-therapy with misoprostol, PPIs, and double-dose H2RAs or use of COX-2-selective inhibitors decrease endoscopic ulcers in patients taking NSAIDs ( 119,120 ) and that misoprostol and COX-2-selective NSAIDs also decrease complicated ulcers in arthritis patients ( 120,121 ). Although these trials suggest that the agents studied may be benefi cial in patients who presented with a bleeding ulcer, they do not specifi cally address management of these high-risk patients.…”

Section: Nsaid Ulcersmentioning

confidence: 99%

Management of Patients With Ulcer Bleeding

Laine

Jensen

2012

American Journal of Gastroenterology

657

547

View full text Add to dashboard Cite

Ulcers are the most common cause of hospitalization for upper gastrointestinal bleeding (UGIB), and the vast majority of clinical trials of therapy for nonvariceal UGIB focus on ulcer disease. Th is guideline provides recommendations for the management of patients with overt UGIB due to gastric or duodenal ulcers. "Overt" indicates that patients present with symptoms of hematemesis, melena, and/or hematochezia. We fi rst discuss the initial management of UGIB in patients without known portal hypertension, including initial assessment and risk stratifi cation, pre-endoscopic use of medications and gastric lavage, and timing of endoscopy. We then focus on the endoscopic and medical management of ulcer disease, including endoscopic fi ndings and their prognostic implications, endoscopic hemostatic therapy, post-endoscopic medical therapy and disposition, and prevention of recurrent ulcer bleeding.Each section of the document presents the key recommendations related to the section topic, followed by a summary of the supporting evidence. A summary of recommendations is provided in Table 1 .A search of MEDLINE via the OVID interface using the MeSH term " gastrointestinal hemorrhage " limited to " all clinical trials " and " meta-analysis " for years 1966 -2010 without language restriction as well as review of clinical trials and reviews known to the authors were performed for preparation of this document. Th e GRADE system was used to grade the strength of recommendations and the quality of evidence ( 1 ). Th e quality of evidence, which infl uences the strength of recommendation, ranges from " high " (further research is very unlikely to change our confi dence in the estimate of eff ect) to " moderate " (further research is likely to have an important impact on our confi dence in the estimate of eff ect and may change the estimate) to " low " (further research is very likely to have an important impact on our confi dence in the estimate of eff ect and is likely to change the estimate), and " very low " (any estimate of eff ect is very uncertain). Th e strength of a recommendation is graded as strong when the desirable eff ects of an intervention clearly outweigh the undesirable eff ects and is graded as conditional when uncertainty exists about the trade-off s ( 1 ). In addition to quality of evidence and balance between desirable and undesirable eff ects, other factors aff ecting the strength of recommendation include variability in values and preferences of patients, and whether an intervention represents a wise use of resources ( 1 ). 2. Blood transfusions should target hemoglobin ≥ 7 g / dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease (Conditional recommendation). Management of Patients With Ulcer Bleeding3. Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care (Cond...

show abstract

Section: Nsaid Ulcersmentioning

confidence: 99%

Management of Patients With Ulcer Bleeding

Laine

Jensen

2012

American Journal of Gastroenterology

657

547

View full text Add to dashboard Cite

show abstract

“…Multiple and interactive mechanisms, including impairments in gastrin regulation, acid secretion, inflammatory response, and neural pathways, contribute to the development of Hpinduced gastric injuries and subsequent consequences (5-7). Use of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin and selective cyclooxygenase (COX)-2 inhibitors, is another risk factor for gastric injuries (8). A variety of changes, such as deficiency in prostaglandins, neutrophil activation, microcirculatory disturbances, oxygen free radicals, and luminal acid, all contribute to the development of NSAID-induced gastric injuries (9,10).…”

Section: Introductionmentioning

confidence: 99%

Helicobacter pylori infection and administration of non-steroidal anti-inflammatory drugs down-regulate the expression of gastrokine-1 in gastric mucosa

Mao

Chen²,

Peng³

et al. 2012

Turk J Gastroenterol

View full text Add to dashboard Cite

Anahtar kelimeler: Helikobakter pilori, non-steroidal anti-enflamatuar ilaç, gastrokin-1, gastrik mukozal hasar Background/aims: Gastrokine-1 is a novel protein that plays an important role in the maintenance of the integrity of the gastric mucosa. However, whether Helicobacter pylori infection and non-steroidal anti-inflammatory drugs, which are known to cause gastric mucosal injuries, affect gastrokine-1 expression in the gastric mucosa is unknown. The aim of the present study was to determine gastric mucosal expression of gastrokine-1 in patients with Helicobacter pylori infection or long-term non-steroidal anti-inflammatory drug administration. Material and Methods: A total of 40 patients with functional dyspepsia (20 with Helicobacter pylori-negative chronic gastritis, and 20 with Helicobacter pylori-positive chronic gastritis), and 37 Helicobacter pylori-negative long-term non-steroidal anti-inflammatory drug users (26 with aspirin, 11 with selective cyclooxygenase-2 inhibitors) were selected. In addition, 20 Helicobacter pylori-negative healthy volunteers were recruited as controls. All subjects underwent endoscopies with biopsies taken

show abstract

“…We agree that patients who take COX-2 inhibitors are still at risk for GI adverse events, when compared to patients who do not take these medications. As shown in a metaanalysis by Rostrom et al [2], high-dose COX-2 inhibitors insignificantly increased the risk of gastric (relative risk or RR 1.22; 95% CI 0.83-1.80) and duodenal (RR, 1.29; 95% CI 0.63-2.66) ulcers, as compared to placebo. However, when compared to ns-NSAIDs, the risk of major GI complications including perforation, ulceration, bleeding, and obstruction were lower in COX-2 inhibitors.…”

Section: To the Editormentioning

confidence: 89%

Reply to the letter regarding “Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: a systematic review and meta-analysis”

Katchamart

2013

J Gastroenterol

View full text Add to dashboard Cite

Comparison of gastrointestinal adverse effects between cyclooxygenase-2(COX-2) inhibitors and non-selective, non-steroidal anti-inflammatory drugs (ns-NSAID) plus proton pump inhibitors (PPI) '' [1]. According to our analyses, the risk of major gastrointestinal (GI) complications was lower in COX-2 inhibitors, as compared to ns-NSAIDs plus PPI. We agree that patients who take COX-2 inhibitors are still at risk for GI adverse events, when compared to patients who do not take these medications. As shown in a metaanalysis by Rostrom et al.[2], high-dose COX-2 inhibitors insignificantly increased the risk of gastric (relative risk or RR 1.22; 95% CI 0.83-1.80) and duodenal (RR, 1.29; 95% CI 0.63-2.66) ulcers, as compared to placebo. However, when compared to ns-NSAIDs, the risk of major GI complications including perforation, ulceration, bleeding, and obstruction were lower in COX-2 inhibitors.The increased risk of peptic ulcer in a cohort study needs to be cautiously interpreted because this study design is susceptible to selection bias resulting in imbalanced prognostic characteristics at baseline. In daily practice, physicians usually prescribe COX-2 inhibitors for patients who are at high risk of developing GI complications, e.g., old age, prior GI ulcer or bleeding, aspirin or anti-coagulant user, and steroid use, whereas patients with low risk are usually treated with ns-NSAIDs. Therefore, the risk of GI complications between COX-2 inhibitors vs. ns-NSAIDs may be comparable or even higher in COX-2 inhibitors.We totally agree that COX-2 inhibitors are associated with increased risk of GI complication. Patients requiring NSAID therapy who are at high risk should receive COX-2 inhibitor and GI protective therapy (e.g., misoprostol or PPI) or alternative therapy for pain control.

show abstract

Gastrointestinal Safety of Cyclooxygenase-2 Inhibitors: A Cochrane Collaboration Systematic Review

Cited by 223 publications

References 78 publications

Management of Patients With Ulcer Bleeding

Management of Patients With Ulcer Bleeding

Helicobacter pylori infection and administration of non-steroidal anti-inflammatory drugs down-regulate the expression of gastrokine-1 in gastric mucosa

Reply to the letter regarding “Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: a systematic review and meta-analysis”

Contact Info

Product

Resources

About