How to decrease the incidence of NSAID induced gastric and duodenal ulcers in high risk individuals?
- 1. When appropriate, use alternative analgesics or topical NSAID formulations.
- 2. Use the lowest dose and frequency of NSAID possible.
- • Nonselective COX inhibitors, COX-2 selective inhibitors, and ASA have all demonstrated a linear dose-response relationship with GI side effects.
- 3. If NSAIDs are required, consider COX-2 selective inhibitors or use of a nonselective NSAID + gastric protective agent.
- • Randomized controlled trials (RCTs) and metaanalyses have demonstrated reduced rates by 50% to 66% of ulcer bleeding and complications with COX-2 selective inhibitors compared with nonselective inhibitors.
- • Proton pump inhibitors (PPIs) and misoprostol (PGE 1 analogue) have each demonstrated reduced rates of bleeding and complications secondary to gastric ulcers among users of nonselective NSAIDs.
- • Agents such as H2 blockers, sucralfate, and antacids may reduce dyspepsia but have not demonstrated a protective effect against ulcer complications.
- • Studies suggest that use of a PPI + nonselective NSAID may afford similar GI protection to that of COX-2 selective inhibitors.
- • Taking a COX-2 selective inhibitor and low-dose ASA has the same GI toxicity as a nonselective NSAID without ASA. Therefore, in high-risk patients on a COX-2 selective NSAID and low-dose ASA, a PPI is needed for GI protection.
- 4. Treatment of an existing H. pylori infection should be done prior to initiation of NSAID.
- • Testing should be considered in high-risk groups; there is no data currently to support routine testing in lower-risk groups.
