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.