Abstract
NSAIDs are among the most commonly used drugs worldwide and their beneficial therapeutic properties are thoroughly accepted. However, they are also associated with gastrointestinal (GI) adverse events. NSAIDs can damage the whole GI tract including a wide spectrum of lesions. About 1 to 2% of NSAID users experienced a serious GI complication during treatment. The relative risk of upper GI complications among NSAID users depends on the presence of different risk factors, including older age (>65 years), history of complicated peptic ulcer, and concomitant aspirin or anticoagulant use, in addition to the type and dose of NSAID. Some authors recently reported a decreasing trend in hospitalizations due to upper GI complications and a significant increase in those from the lower GI tract, causing the rates of these two types of GI complications to converge. NSAID-induced enteropathy has gained much attention in the last few years and an increasing number of reports have been published on this issue. Current evidence suggests that NSAIDs increase the risk of lower GI bleeding and perforation to a similar extent as that seen in the upper GI tract. Selective cyclooxygenase-2 inhibitors have the same beneficial effects as nonselective NSAIDs but with less GI toxicity in the upper GI tract and probably in the lower GI tract. Overall, mortality due to these complications has also decreased, but the in-hospital case fatality for upper and lower GI complication events has remained constant despite the new therapeutic and prevention strategies.
Highlights
More than 5,000 years have passed since a Greek physician prescribed extracts of willow bark for musculoskeletal pain
A meta-analysis of 16 studies showed that the odds ratio for peptic ulcer in patients with both risk factors (H. pylori-positive nonsteroidal anti-inflammatory drug (NSAID) use) was 61.1), compared with H. pylorinegative nonusers [11]
A 2007 systematic review of randomized controlled trials (RCTs) showed that selective COX-2 inhibitors produced significantly fewer ulcers (RR, 0.26; 95% confidence interval (CI), 0.23 to 0.30) and ulcer complications (RR, 0.39; 95% CI, 0.31 to 0.50) as well as better GI tolerability compared with ns-NSAIDs [15]
Summary
More than 5,000 years have passed since a Greek physician prescribed extracts of willow bark for musculoskeletal pain. Epidemiology Recent publications have shown that the incidence of lower GI complications (including ulceration, bleeding, obstruction or perforation), many of them related to NSAID and ASA use, is increasing whereas the incidence of upper GI complications is decreasing [28] (Figure 1). The authors concluded the need to review the actual preventive strategies for chronic NSAID users Another clinical side effect associated with NSAID use in the lower GI tract is complicated diverticular disease. Abbreviations ASA, acetylsalicylic acid; CE, capsule endoscopy; CI, confidence interval; CONDOR, Celecoxib versus Omeprazole and Diclofenac in Patients with Osteoarthritis and Rheumatoid Arthritis; COX, cyclooxygenase; CV, cardiovascular; GI, gastrointestinal; MEDAL, Multinational Etoricoxib and Diclofenac Arthritis Long-term; NSAID, nonsteroidal anti-inflammatory drug; ns-NSAID, nonselective nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor; RCT, randomized controlled trial; RR, relative risk; VIGOR, Vioxx Gastrointestinal Outcomes Research. Author details 1Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/ Domingo Miral s/n, 50009 Zaragoza, Spain. 2Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain. 3CIBERehd, c/Córcega 180 bajos dcha, 08036 Barcelona, Spain. 4University of Zaragoza, c/Pedro Cerbuna s/n, 50009 Zaragoza, Spain
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