Management of High-risk Patients on Non-steroidal Anti-inflammatory Drugs or Aspirin

Abstract

Low-dose aspirin is increasingly used for the primary prevention of cardiovascular events. However, current evidence suggests that the gastrointestinal and other bleeding risks of aspirin probably outweigh its potential benefits in primary prevention. Various strategies have been proposed to reduce the gastrointestinal risk of aspirin, including gastroprotection with a proton pump inhibitor (PPI), eradication of Helicobacter pylori infection and replacing aspirin with other anti-platelet agents. Although co-therapy with a PPI and the eradication of H. pylori substantially reduce the risk of recurrent ulcer bleeding with aspirin, the replacement of aspirin by clopidogrel cannot be recommended to patients with a high gastrointestinal risk. Traditionally, strategies for the prevention of non-steroidal anti-inflammatory drug (NSAID)-induced ulcer complications included co-therapy with a gastroprotective agent and the substitution of cyclooxygenase (COX)-2 inhibitors for non-selective NSAID. Evidence emerged recently that COX-2 inhibitors and some non-selective NSAID increase cardiovascular risk. Before prescribing anti-inflammatory therapy, both gastrointestinal and cardiovascular risk factors of individual patients need to be evaluated. In patients with increased cardiovascular risk requiring anti-inflammatory analgesics, the combination of a non-selective NSAID, low-dose aspirin and a PPI is the preferred treatment.