The use of proton pump inhibitors in treating and preventing NSAID-induced mucosal damage

James M Scheiman

doi:10.1186/ar4177

Abstract

NSAIDs are prescribed widely but have rare serious gastrointestinal side effects. More recently, adverse cardiovascular effects of these drugs have also been recognized, leading to the withdrawal of some agents and continuing uncertainty about the best approach for patients requiring NSAID therapy. Proton pump inhibitors (PPIs) provide potent and long-lasting inhibition of gastric acid secretion and have proven efficacy in healing NSAID-associated ulcers, including those with continued exposure to NSAIDs. PPIs have also shown efficacy in reducing the risk of ulcerations due to NSAID use compared with NSAIDs alone in randomized controlled trials (RCTs) where endoscopic ulcers are used as the primary endpoint, albeit a surrogate marker for clinical ulcers and complications. Large RCT outcome trials comparing patients exposed to NSAIDs with and without PPI co-therapy have not been performed, but adequately powered RCTs in high-risk patients demonstrate that PPI + nonselective NSAID provides similar rates of symptomatic ulcer recurrence rates as the use of a cyclooxygenase (COX)-2 selective inhibitor. A RCT in high-risk patients with previous ulcer complications supports the additive bene3 t of two risk-reducing strategies, as ulcer complication recurrence was eliminated in high-risk patients who were given a COX-2 selective agent with a PPI. Helicobacter pylori, an independent risk factor for ulcers, should be sought out and eradicated in patients at increased gastrointestinal risk, typically those with an ulcer history. Following H. pylori eradication, however, patients remain at risk and co-therapy with a PPI is recommended. NSAID medication selection should consider both the individual patients' gastrointestinal and cardiovascular risks.

Highlights

Other articles in this supplement have reviewed the benefits of NSAID therapy
These drugs were widely prescribed until evidence of cardiovascular side effects, including an increased risk of myocardial infarction, gradually began to emerge, and some of the COX-2 NSAIDs were eventually withdrawn from general use in Europe and North America [3]
In that study we demonstrated for the first time that pump inhibitors (PPIs) provided ulcer risk reduction for nonselective NSAID exposure, and for patients taking COX-2 selective agents as well

Summary

Introduction

Other articles in this supplement have reviewed the benefits of NSAID therapy. Their efficacy leads to a vast exposure of these medications in diverse patient populations. Treatment of NSAID-associated ulcers Understanding the evolution in research that provided the basis of PPI therapy for NSAID users began with comparative studies with the well-established, but less potent, acid-suppressive agents that predated PPI use.

Results

Conclusion