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  • NSAID Gastrointestinal Adverse Effects

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NSAID Gastrointestinal Adverse Effects

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  1. See Also
    1. NSAID
    2. NSAID Alternatives
  2. Risk factors for NSAID related GI adverse effects
    1. Age over 60 years (decreased GI protection)
    2. Peptic Ulcer Disease history
    3. Concurrent Corticosteroid use
    4. Concurrent oral Anticoagulation (Coumadin, Aspirin)
    5. High dose NSAID
  3. Relative Risks of GI adverse effects
    1. Lowest Risk: COX2 Inhibitors (Selective)
      1. Celecoxib (Celebrex)
      2. Rofecoxib (Vioxx)
    2. Low Risk (Non-Selective NSAIDs)
      1. Ibuprofen 1.0
      2. Fenoprofen (Nalfon) 1.6
      3. Aspirin 1.6
      4. Diclofenac (Voltaren) 1.8
      5. Sulindac (Clinoril) 2.1
      6. Nabumetone (Relafen)
      7. Etodolac (Lodine)
      8. Salsalate
    3. Medium Risk
      1. Diflunisal (Dolobid) 2.2
      2. Naproxen (Naprosyn) 2.2
      3. Indomethacin (Indocin) 2.4
      4. Tolmetin (Tolectin) 3.0
    4. High Risk
      1. Piroxicam (Feldene) 3.8
      2. Ketoprofen (Orudis) 4.2
      3. Azapropazone 9.2
      4. Flurbiprofen (Ansaid)
  4. Gastroduodenal Ulcer Incidence by endoscopy (12 weeks)
    1. Naprosyn: 35%
    2. Ibuprofen: 23-29% (2 different trials)
    3. Diclofenac: 10%
    4. Rofecoxib: 5-8% (25-50 mg)
    5. Celecoxib: 7%
    6. Placebo: 4-7% (2 different trials)
    7. References
      1. (1999) Med Lett Drugs Ther 41(1045):11
      2. Laine (1999) Gastroenterology 116:A229
  5. Prophylaxis
    1. General
      1. Always use NSAID with food or milk
      2. COX2 Inhibitors have no advantage over standard NSAID
      3. Consider screening for Helicobacter Pylori before use
    2. Indications for prophylaxis (avoid NSAIDs if possible)
      1. Age over 75 years
      2. Concurrent Warfarin therapy
      3. History of Peptic Ulcer Disease
      4. History of Gastrointestinal Bleeding
      5. History of Coronary Artery Disease
    3. Misoprostol (Cytotec)
      1. Dose: 100-200 ug tid to qid
      2. Replaces prostaglandins at stomach lining
      3. Allows use of NSAIDS in Peptic Ulcer Disease
      4. Causes significant dose limiting Diarrhea
    4. Sucralfate
      1. Ineffective at preventing NSAID related Peptic Ulcers
    5. H2 Receptor Antagonists (e.g. Zantac, Tagamet)
      1. Not recommended (may mask GI symptoms)
      2. Prevents Duodenal Ulcer, not Gastric Ulcer
      3. Consider high dose H2 Antagonist
    6. Omeprazole
      1. Heals, but may not protect from formation
  6. References
    1. Henry (1996) BMJ 312:1563
    2. (1999) Med Lett Drugs Ther 41(1045):11

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