Prevention and treatment of NSAID-induced gastroduodenal injury

Abstract

NSAIDs increase the risk of gastrointestinal (GI) complications. Those at risk should be considered for alternatives to NSAID therapy, modifications of risk factors, and prevention strategies with co-therapy with gastroprotective agents (proton-pump inhibitors or misoprostol) or COX-2 selective inhibitors (coxibs). Since coxibs, and probably other nonselective NSAIDs, may increase the risk of cardiovascular events, prevention strategies must take into account both GI and cardiovascular risk factors. All NSAIDs and coxibs should be prescribed at the lowest possible dose and for the shortest period of time. In patients with GI risk factors but no cardiovascular risk, coxibs or NSAIDs plus PPI or misoprostol are valid options. Patients with a history of ulcer bleeding should receive coxib plus PPI therapy and should be tested and treated for Helicobacter pylori infection. Most patients with increased cardiovascular risk will be treated with antiplatelet agents. It is not known whether co-therapy with low-dose aspirin will reduce the incidence of cardiovascular events, but it will further increase GI risk. It is currently unclear whether the risk of developing upper GI events with coxib plus aspirin is lower than it is with NSAIDs plus aspirin. However, all these patients should benefit from PPI co-therapy. Helicobacter pylori eradication should be considered as an additional therapeutic option when we want to further reduce the GI risk in specific patients. When the lower GI tract is of concern, coxib rather than NSAID therapy should be considered as the first option. Coxib therapy has better GI tolerance than NSAIDs, but patients with peptic ulcers or dyspepsia during NSAID/coxib treatment need PPI co-therapy.

Perioperative acute upper gastrointestinal haemorrhage in older patients with hip fracture: incidence, risk factors and prevention

“…In one report, patients with in‐hospital AGIH were less likely to have a previous history of ulcer disease, H. pylori infection, chronic active gastritis or the ingestion of NSAIDs than those who presented to hospital with bleeding from peptic ulcers 33 . Our findings are consistent with numerous previous studies demonstrating that history of peptic ulcer, 37 active smoking, 7, 9, 25 blood group O 38 and the use of NSAIDs or aspirin 10, 13, 39 are strong predictors of AGIH. However, ours is the first study to confirm the importance of these RFs in older HF patients.…”

Use of antisecretory drugs among consumers of non‐steroidal anti‐inflammatory drugs in the general population

“…Another debatable point is whether history of ulcer as reported by the patients themselves is a risk factor equivalent to history of peptic ulcer disease from an objective source; persons with previously substantiated objective history of ulcer are probably overestimated, but this situation is frequent in clinical practice and there is evidence that reported ulcer also represents a risk factor of gastroduodenal lesions. 5 Lastly, the lack of data on misoprostol is noteworthy, as it is an effective drug 28,29 Nevertheless, its low tolerability reduces its use, judging by the use reported in other studies. 6,7,25,30 The appropriateness of preventive strategies depends both on clinical (efficacy of the preventive measure) and on financial (cost-effectiveness) issues.…”

Prescription patterns and appropriateness of NSAID therapy according to gastrointestinal risk and cardiovascular history in patients with diagnoses of osteoarthritis

“…Among pharmacological treatments, NSAIDs are commonly prescribed because of their clinical efficacy, despite the well-known gastrointestinal (GI) side effects associated with their use [3]. Cyclooxigenase-2 (COX-2)-selective NSAIDs were developed to diminish the GI adverse events caused by non-selective NSAIDs (nsNSAIDs) [4].…”