European physicians don’t like cytoprotective agents?

Abstract

Major differences are evident between Japanese and Western practice in the prevention of gastrointestinal injury caused by low-dose aspirin (LDA) and nonsteroidal anti-inflammatory drugs (NSAIDs). The proportion of physicians prescribing gastroprotective agents with NSAIDs and LDA with the aim of preventing gastrointestinal injury is 77% in Japan(1) and between 70-84% in Spain,(2) showing the great majority prescribe something to protect the stomach in both countries. The gastroprotective agent prescribed, however, is a proton pump inhibitor (PPI) in 99.4% of cases in Spain,(2) whereas in Japan only 37% of prescriptions are for a PPI, with a similar proportion for cytoprotective agents (CP). If we include combination therapy with a PPI or H2-receptor antagonist (H2RA) + CP, then CP are the most commonly prescribed gastroprotective agents in Japan.(1) It is not that European physicians do not like CP, rather they are fully aware of the gastrointestinal mucosal protective effects of CP.(3-5) PPIs are clearly superior to CP in the prevention of upper gastrointestinal bleeding caused by NSAIDs and LDA. However, gastrointestinal injury caused by NSAIDs and LDA is not confined to only the upper gastrointestinal tract (oesophagus, stomach and duodenum), but can also involve the small and large intestines. Some CP have been reported to prevent NSAID-associated injury to the small intestine.(6) PPIs have few protective effects on the small intestine, so we can anticipate that PPI + CP combination therapy will protect the entire gastrointestinal tract including the small intestinal mucosa. Strategies for protection against damage to the gastrointestinal tract caused by NSAIDs and LDA will vary between countries according to differences in medical insurance systems, as well as differences in the availability of medical services. Each country should produce its own strategy. In Japan, we need to produce evidence for CP in preventing damage caused by NSAIDs and LDA, and develop strategies stratified according to the degree of risk of background.