Risk Of Gastrointestinal Complications Research Articles

Development and validation of a risk prediction model for postoperative gastrointestinal complications in patients undergoing aortic arch surgery

Background Postoperative gastrointestinal complications (GICs) were potentially fatal to patients who underwent aortic arch surgery. The aim of this study was to construct a prediction model of GICs. Methods We retrospectively studied the medical records of 3063 patients who underwent aortic arch surgery. Patients were randomly divided into derivation and validation cohorts at a ratio of 4:1. A nomogram was constructed in the derivation cohort. Results A total of 157 patients with GICs were identified. In the derivation cohort, multivariate analysis identified six predictors of GICs including hypertension, ASA classification, preinduction MAP, aortic cross-clamp time, CPB time, and intraoperative transfusion of red blood cells. Compared with the patients without GICs, the patients with GICs had higher mortality, and longer ICU and hospital stays. We also divided the patients into four intervals according to the risk of GICs. Conclusions This study developed a reliable prediction model of GICs after aortic arch surgery. This prediction model had been well verified in our research centre, and further external verification was required before it can be recommended for clinical application.

Risk of Gastrointestinal Complications in Post Laparoscopic Cholecystectomy

Background: Post-cholecystectomy is related with a significant risk of developing gastrointestinal symptoms which affect the quality of life of patients. Objective: To assess the gastrointestinal complications risks in post-cholecystectomy patients (laparoscopic). Study Design: Retrospective study Place and Duration of Study: Department of Surgery, Services Hospital, Lahore from 1st April 2020 to 31st March 2021. Methodology: One hundred and fifty patients were enrolled. All patients under went laparoscopy for their acute or chronic cholelithiasis treatment. Patients demographic, body mass index, clinical assessment was documented. Patients were followed up for a period of six months and their gastrointestinal complains were recorded. Results: There were 86 females and 64 males with a mean age 49.8±6.3 years and mean body mass index were 24.8±3.6 kg/m2. Diarrhoea and fat intolerance were main complains within 56% and 57.3% patients within three months respectively. Flatulence, fat intolerance and right upper quadrant pain was also main complains of patients. Conclusion: Risk of diarrhoea, right upper quadrant pain, flatulence, and fat intolerance are noticeable as gastrointestinal complication in laparoscopic post-cholecystectomy patients. Keywords: Post-cholecystectomy, Gastrointestinal complications, Diarrhoea

Вибір оптимального інгібітору протонної помпи для пацієнтів з ішемічною хворобою серця, які потребують проведення подвійної антитромбоцитарної терапії

Висока захворюваність і смертність від серцево-судинних захворювань призвели до необхідності широкого використання антитромбоцитарних засобів у клінічній практиці. Найбільш перспективною вважається комбінована антиагрегантна терапія з використанням препаратів, що мають різні механізми впливу на тромбоцитарну ланку гемостазу, за рахунок чого можна досягти вираженого синергічного ефекту. У нашій країні переважно призначається комбінація ацетилсаліцилової кислоти і клопідогрелю, яку часто називають подвійною антитромбоцитарною терапією (ПАТ). Для зменшення ризиків розвитку шлунково-кишкових ускладнень при використанні ПАТ рекомендований прийом інгібіторів протонної помпи (ІПП), проте в деяких дослідженнях згадується, що одночасне призначення ІПП та клопідогрелю в перспективі підвищує ризик виникнення несприятливих серцево-судинних подій, до яких відносять інфаркт міо-карда, інсульт, нестабільну стенокардію, необхідність повторних коронарних втручань і коронарну смерть. У зв’язку з цим представляється актуальною проблема розробки підходів диференційованого застосування ІПП у пацієнтів, які отримують ПАТ. Надано огляд літератури з означеної вище проблематики, наведено результати досліджень із вивчення впливу різних ІПП на клінічні наслідки у хворих, які приймають клопі-догрель.

New aspects of pain management in acute and chronic inflammatory syndromes

Effective pain control is one of the first and most important challenges in medical practice. Non-steroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of treatment for acute and chronic inflammatory pain syndromes. Of particular interest is a group of patients with a low risk of cardiovascular development and a low to moderate risk of gastrointestinal complications, for whom any NSAID may be recommended. Their choice may depend on the duration and severity of the inflammatory process. The most high analgesic potential have non-selective inhibitors of cyclooxygenase – diclofenac and ketoprofen. Modern technologies give great opportunities for modifying the active substance of NSAIDs and improvement of the drug dosage form in order to hasten their effects and enhance analgesic and anti-inflammatory effect of drugs. In the new form of diclofenac (Dialrapid sachet), sodium salt was replaced by potassium salt, which provided a high rate of both absorption of the active substance and action, comparable to that with intramuscular administration of the drug. It also expanded the possibilities of its use for acute pain and relapses of pain relief in exacerbation of chronic inflammatory diseases. The inclusion of lysine salt significantly changed the pharmacodynamics of ketoprofen. Unlike conventional ketoprofen, its lysine salts (Artrozilen and OKИ) are fast-dissolving compounds with neutral pH that do not irritate the mucous membrane of the gastrointestinal tract, which makes them suitable for long-term treatment of chronic inflammatory pain syndromes.

Effect of probiotics, Bifidobacterium bifidum G9-1, on gastrointestinal symptoms in patients with type 2 diabetes mellitus: study protocol for open-label, single-arm, exploratory research trial (Big STAR study).

Metformin is associated with risks of gastrointestinal complications in patients with type 2 diabetes. In contrast, probiotic Bifidobacterium bifidum G9-1 (BBG9-1) could improve the symptoms of diarrhea caused by metformin in animal models. Thus, the primary outcome of this study will be the effect of the probiotic BBG9-1 on gastrointestinal symptoms, including diarrhea, in patients with type 2 diabetes who use metformin. This open-label, single-arm, and exploratory study will examine 40 patients with type 2 diabetes who use metformin and have symptoms of constipation or diarrhea. After the baseline examination (objective 1), patients will be administered probiotic BBG9-1 for 10 ± 2 weeks. Then, examinations will be performed (objective 2). The primary outcome will be changes in the symptoms of constipation or diarrhea from objective 1 to objective 2. Secondary outcomes will include changes in gut microbiota, and correlations between changes in fecal properties and biomarkers, including HbA1c level and body mass index. This is the first study to investigate the effect of probiotic BBG9-1 on the change in the symptom of constipation or diarrhea in patients with type 2 diabetes who use metformin.

Perioperative intraperitoneal metabolic markers in patients undergoing cardiac surgery with cardiopulmonary bypass: an exploratory pilot study

Cardiopulmonary bypass and postoperative cardiac dysfunction cause splanchnic hypoperfusion resulting in intra-abdominal anaerobic metabolism and risk for gastrointestinal complications. The intra-abdominal metabolism can be monitored by intraperitoneal measurement of relevant metabolites using microdialysis. The aim of this study was to investigate the intraperitoneal metabolism using microdialysis during and after cardiopulmonary bypass at 34°C. In six patients undergoing elective coronary artery bypass grafting or aortic valve replacement under cardiopulmonary bypass, microdialysis was used to measure intraperitoneal and subcutaneous glucose, lactate, pyruvate, glycerol and glutamate concentrations, intraoperatively and up to 36 hours postoperatively. Arterial and central venous blood gases were analysed as were haemodynamics and the development of complications. All patients had an ordinary perioperative course and did not develop gastrointestinal complications. The arterial, intraperitoneal and subcutaneous lactate concentrations changed during the perioperative course with differences between compartments. The highest median (interquartile range) concentration was recorded in the intraperitoneal compartment at 1 hour after the end of cardiopulmonary bypass (2.1 (1.9-2.5) mM compared to 1.3 (1.2-1.7) mM and 1.5 (1.0-2.2) mM in the arterial and subcutaneous compartments, respectively). In parallel with the peak increase in lactate concentration, the intraperitoneal lactate/pyruvate ratio was elevated to 33.4 (12.9-54.1). In cardiac surgery, intraperitoneal microdialysis detected changes in the abdominal metabolic state, which were more pronounced than could be shown by arterial blood gas analysis. Despite an uneventful perioperative course, patients undergoing low-risk surgery under cardiopulmonary bypass might be subjected to a limited and subclinical intra-abdominal anaerobic state.

Indomethacin Does Not Reduce Heterotopic Ossification In Two-incision Distal Biceps Repairs

Objectives:Our objective was to evaluate whether indomethacin would reduce the incidence of heterotopic ossification (HO) after two-incision distal biceps repairs.Methods:After obtaining IRB approval, all two-incision distal biceps tendon repairs performed between 2008 and 2015 by 17 surgeons in a multi-center (14) integrated, health care system were retrospectively reviewed. Indomethacin use was confirmed by the use of our pharmacy database search of a prescription being filled 10 days prior and up to 6 weeks after to surgery. A minimum of 1 year of follow-up was required for all patients. Variables recorded were patient demographics, time from injury to surgery, re-operation rate, infection, re-rupture, nerve complications, and time to release from medical care. Inclusion criteria included age 18 and over, primary repairs using the two-incision technique with bone tunnel - suture fixation. A Fischer Exact test was performed to test for significance.Results:146 patients met our inclusion criteria. The average age was 48 years (range: 23-69). All (100%) were male. The non-dominant side was involved in 76 patients (52.1%). There was no difference in age, gender, time from injury to surgery in groups receiving indomethacin to those not receiving it (P>0.05). 109 (74.7%) patients underwent distal biceps repair without indomethacin and 6 (5.5%) patients developed HO. In 37 patients who received indomethacin prophylaxis, 5 (13.5%) patients developed HO. There was no statistically significant difference in HO formation between patients who received indomethacin prophylaxis and those who did not (P=0.14).Conclusion:Based on our findings and the risk of gastrointestinal complications, we do not recommend indomethacin prophylaxis for two-incision distal biceps repairs.

Annals for Educators - 5 December 2017

Annals for Educators - 5 December 2017

Prescription pattern of NSAIDS and the prevalence of NSAID-induced gastrointestinal risk factors of orthopaedic patients

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used medications in the world. NSAID-induced adverse reactions involve upper gastrointestinal (GI) tract complications, which can be life-threatening. Objectives: The study was conducted to explore the current prescription pattern of non-steroidal anti-inflammatory drugs (NSAIDs) and the prevalence of NSAID-induced gastrointestinal(GI) risk factors of orthopedic adult inpatient.Materials and methods: A prospective observational NSAIDs induced GI risk related study was conducted over a period of 6 months by clinical pharmacist. Study cohort included 105 orthopaedic inpatients who are taking or will be taking NSAIDs for more than a week. A self-administered questionnaire was completed by each patient. A simplified risk scoring scale (the Standardized Calculator of Risk for Events; SCORE) was used to measure patients‟ risk for GI complications. The pattern of NSAIDs prescription was identified from medical recordings.Results: The study groups were stratified into four risk groups according to GI SCORE tool, 27.6% of the patients belonged to high risk or very high risk groups for GI complications. Analysis of prescription pattern revealed that 11.4% of the patients aged over 65 yr, 19% with co morbid disease were prescribed with COX-2 selective inhibitor. Conclusion: In this study assessment of prescription pattern and GI risk factors for NSAIDs were evaluated and in conclusion, physician‟s considerate prescription of NSAIDs with well-understanding of each patient‟s GI risk factors is strongly encouraged to prevent serious GI complications

THERAPEUTIC EFFECTS OF PINOCEMBRIN ON INDOMETHACIN-INDUCED GASTRIC ULCER MODEL IN RATS

Indomethacin considered one of the most commonly used NSAIDs to treat pain and inflammation among elder patients. Ironically, it has high risk of gastrointestinal complication, ulceration and in some cases perforation. Pinocembrin is one of the natural flavonoid present in honey and posses anti-inflammatory, anti-oxidant, and anti-apoptotic activities. The present study was conducted to investigate the possible therapeutic effects of Pinocembrin on indomethacin induced gastric ulcer model in rats. Animals either pre-treated with pinocembrin 50mg/kg for 3 days before ulcer induction with one single dose of indomethacin (48 mg/kg) orally or post-treated with pinocembrin 50mg/kg/3 days and 50mg/kg/5days after 1 hr of ulcer induction with same dose of indomethacin. The therapeutic effects were determined via measuring oxidative stress markers as well as histopathological investigation. Pinocembrin protected gastric tissues which was confirmed histopathologically. It also increased levels of CAT, GSH and decreased levels of MDA enzymes. In conclusion, these findings show that pinocembrin have therapeutic effects in indomethacin induced gastric ulcer.

Efficacy of aspirin (325 mg) + omeprazole (40 mg) in treating coronary artery disease

ABSTRACTIntroduction: Aspirin is indicated for primary and secondary prevention of cardiovascular diseases (CVD) by major guidelines. However, its use may be associated with gastrointestinal (GI) toxicities, including, but not limited to, GI bleeding. This may lead to increased morbidity and mortality, as well as diminished compliance, which again leads to increased risk of major cardiovascular events. Modified formulations of aspirin often have comparable risks of GI toxicity despite their dose or formulation and have had limited success to prevent GI toxicities. Simultaneous treatment with Proton pump inhibitors (PPIs) has been used successfully to prevent GI toxicities from aspirin. However, addition of an extra medication may lead to lower compliance and hence ineffective or less than optimal treatment.Areas covered: After a selective literature search, a brief review of the available evidence regarding GI toxicity of aspirin and the protective effects of PPIs was conducted. The concept of combination tablets, and the available data about Aralez Pharmaceuticals’ YOSPRALA (aspirin (81 mg or 325 mg) and omeprazole (40 mg) fixed dose combination tablet being evaluated for secondary prevention of cardiovascular and cerebrovascular events in patients at risk for GI complications of aspirin therapy) is also presented.Expert opinion: The available evidence suggests that PPIs are the best option to prevent aspirin-related GI toxicities, but compliance is low in people who are prescribed both aspirin and PPI. Combination tablets containing both aspirin and a PPI may be a good option for providing protection against GI toxicities in people who require aspirin for secondary prevention of cardiovascular diseases.

Ischemic colitis in a cardiac surgical patient—a diagnostic and management challenge

Ischemic colitis in cardiac surgical patients is a rare entity. The presence of multiple comorbidities and potential complications related to surgery can put patients at high risk of gastrointestinal complications. The clinical presentation of ischemic colitis often can be confused with pseudo-membraneous colitis and the more ominous mesenteric infarction. The potentially morbid nature of the differential diagnoses calls for a precise and early diagnosis of this condition. Also, the relative difficulty in reliably coming to a diagnosis makes this condition particularly challenging in paralyzed patients on ventilator or with altered sensorium. Although, ischemic colitis has a relatively benign clinical course in majority of the cases, the economic and psychosocial impact of this pathology can be substantial. The potential for longstanding complications like chronic intestinal strictures warrant a long-term follow-up plan for those afflicted. Here, we present a cardiac surgical patient with multiple comorbidities whose clinical recovery was complicated by an episode of ischemic colitis following off pump coronary artery bypass surgery.

Risk of gastrointestinal complications in cancer patients treated with immune checkpoint inhibitors: a meta-analysis.

We performed a meta-analysis of the risk of selected gastrointestinal toxicities associated with immune checkpoint inhibitors. Eligible studies included randomized trials of patients with solid tumors on ipilimumab, nivolumab, pembrolizumab, tremelimumab, pidilizumab and atezolizumab, describing events of diarrhea, vomiting or colitis. After exclusion of ineligible studies, a total of ten clinical trials were considered eligible for the meta-analysis. The relative risk of all-grade diarrhea, vomiting and colitis was 1.64 (95% CI: 1.19-2.26; p = 0.002), 0.72 (95% CI: 0.49-1.07; p = 0.1), 10.35 (95% CI: 5.78-18.53; p < 0.00001), respectively. Our meta-analysis has demonstrated that immune checkpoint inhibitors are associated with a significantly increased risk of all grade and high-grade colitis.

Mesenteric near-infrared spectroscopy and risk of gastrointestinal complications in infants undergoing surgery for congenital heart disease.

We hypothesised that lower mesenteric near-infrared spectroscopy values would be associated with a greater incidence of gastrointestinal complications in children weighing <10 kg who were recovering from cardiac surgery. We evaluated mesenteric near-infrared spectroscopy, central venous oxygen saturation, and arterial blood gases for 48 hours post-operatively. Enteral feeding intake, gastrointestinal complications, and markers of organ dysfunction were monitored for 7 days. A total of 50 children, with median age of 16.7 (3.2-31.6) weeks, were studied. On admission, the average mesenteric near-infrared spectroscopy value was 71±18%, and the systemic oxygen saturation was 93±7.5%. Lower admission mesenteric near-infrared spectroscopy correlated with longer time to establish enteral feeds (r=-0.58, p<0.01) and shorter duration of feeds at 7 days (r=0.48, p<0.01). Children with gastrointestinal complications had significantly lower admission mesenteric near-infrared spectroscopy (58±18% versus 73±17%, p=0.01) and higher mesenteric arteriovenous difference of oxygen at admission [39 (23-47) % versus 19 (4-27) %, p=0.02]. Based on multiple logistic regression, admission mesenteric near-infrared spectroscopy was independently associated with gastrointestinal complications (Odds ratio, 0.95; 95% confidence interval, 0.93-0.97; p=0.03). Admission mesenteric near-infrared spectroscopy showed an area under the receiver operating characteristic curve of 0.76 to identify children who developed gastrointestinal complications, with a suggested cut-off value of 72% (78% sensitivity, 68% specificity). In this pilot study, we conclude that admission mesenteric near-infrared spectroscopy is associated with gastrointestinal complications and enteral feeding tolerance in children after cardiac surgery.

The proportion of all previous patients was a potential instrument for patients' actual prescriptions of nonsteroidal anti-inflammatory drugs

ObjectivesTo investigate whether physician's prescribing preference is a valid instrumental variable (IV) for patients' actual prescription of selective cyclooxygenase-2 (COX-2) inhibitors in the German Pharmacoepidemiological Research Database (GePaRD). Study Design and SettingWe compared the effect of COX-2 inhibitors vs. traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) on the risk of gastrointestinal complications using physician's preference as IV. We used different definitions of physician's preference for COX-2 inhibitors. A retrospective cohort of new users was built which was further restricted to subcohorts. We compared IV-based risk difference estimates, using a two-stage approach, to estimates from conventional multivariate models. ResultsWe observed only a small proportion of COX-inhibitor users (3.2%) in our study. All instruments, in the full cohort and in the subcohorts, reduced the imbalance in most of the covariates. However, the IV treatment effect estimates had a highly inflated variance. Compared to the most recent prescription, the proportion of previous patients was a stronger instrument and reduced the variance of the estimates. ConclusionThe proportion of all previous patients is a potential IV for comparing COX-2 inhibitors vs. tNSAIDs in GePaRD. Our study demonstrates that valid instruments in one health care system may not be directly applicable to others.

Acute Fetal Asphyxia After Gastric Rupture in a Pregnant Patient With a Gastric Band

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.

Difference in risk of gastrointestinal complications between users of enteric-coated and buffered low-dose aspirin

Difference in the risk of gastrointestinal (GI) complications between users of enteric-coated and buffered low-dose aspirin (LDA) is unclear. The purpose of the study is to examine the difference in risk of GI damage between enteric-coated and buffered LDA products. A large and chronologically organized receipt database constructed by a database vendor was utilized. Prescription and event sequence symmetry analysis was used to identify the risk of LDA-induced GI complications over the period from January 2005 to July 2011. LDA use in combination with H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) was examined by prescription sequence symmetry analysis. Likewise, symmetry analysis was undertaken to evaluate the association between the diagnosis of GI disease and the prescription of LDA products. In July 2011, enteric-coated LDA users were more frequently co-administered PPIs than buffered LDA users (25.4% vs. 14.4%). Prescription sequence symmetry analysis of acid inhibitor use found no significant associations with enteric-coated LDA use and buffered LDA use. The event sequence symmetry analysis of ulcer, gastritis and duodenitis, and melena found significant associations with entericcoated LDA use, with adjusted sequence ratios (ASRs) of 1.58 (1.23 - 2.06), 1.30 (1.03 - 1.65), and 14.38 (2.19 - 607.95), respectively, at the 6-month interval. At the 12-month interval, analysis of ulcers and melena found significant associations for enteric-coated LDA users, with ASRs of 1.39 (1.13 - 1.73) and 20.83 (3.33 - 863.25), respectively. Our findings do not support that there is no difference in the risk of GI complications between enteric-coated LDA and buffered LDA, but rather may imply that the risk of GI complications associated with enteric-coated LDA is higher than that with buffered LDA.

An integrated systematic review and meta-analysis of published randomized controlled trials evaluating nasogastric against postpyloris (nasoduodenal and nasojejunal) feeding in critically ill patients admitted in intensive care unit

This article presents the systematic review of the randomized, controlled trials comparing the effectiveness of nasogastric (NG) versus postpyloris (PP) feeding in critically ill surgical patients and other patients in intensive therapy unit (ITU). Twenty randomized trials recruiting 1496 patients were retrieved from the standard electronic databases. There were 760 patients in the NG feeding group and 736 patients in the PP feeding group. There was significant heterogeneity among trials. PP feeding in ITU patients was associated with lower gastric residual volume (odds ratio (OR), 3.95; 95% confidence interval (CI), 1.19, 13.14; z = 2.24; P<0.03; I(2) = 73%) and a reduced risk of developing aspiration pneumonia (OR, 1.41; 95% CI, 1.01, 1.98; z = 2.03; P<0.04; I(2) = 10%) compared with NG feeding. In addition, higher proportion of caloric requirements (standardized mean difference, -1.02; 95% CI, -1.73, -0.31; z = 2.82; P<0.005; I(2) = 95%) could be delivered with PP feeding. Risk of gastrointestinal complications, overall mortality and length of ITU stay were similar between the two techniques of enteral feeding. In summary, PP feeding in ITU patients reduces the gastric residual volume and risk of aspiration pneumonia. PP feeding is also superior to NG feeding in terms of delivering higher proportion of daily caloric requirements. PP feeding with the help of nasoduodenal or nasojejunal tube may be used routinely in ITU patients for nutritional support.

Gastrointestinal Complications after Cardiac Surgery: Eight Years Experience in a Single Center

Background: The aim of this study was to evaluate the frequency of gastrointestinal complications (GICs) and associated risk factors in patients after cardiac surgery, and to stratify them according to the risk of developing GICs in order to improve our diagnostic protocols.Methods: A total of 5959 patients who underwent cardiac surgery within a period of 97 months were retrospectively evaluated. Surgical procedures included coronary artery bypass grafting, heart valve surgery, aortic surgery, surgical correction of adult congenital heart defects, or combined procedures.Results: The frequency of GICs was 1.3% (75 patients). Intestinal ischemia and upper or lower gastrointestinal bleeding were the most common GICs. From 27 patients affected by intestinal ischemia, 21 patients were previously treated with intra-aortic balloon pump (p < 0.001). Low cardiac output, renal failure or dysfunction, renal risk, peripheral arterial disease, history of myocardial infarction, male gender, intra-aortic balloon pump, cardiopulmonary bypass time, aortic cross-clamp time, duration of intubation, SIRS, and MODS were associated with significantly increased risk of GICs. Conclusions: To decrease the occurrence of intestinal ischemia, we suggest that placement of intra-aortic balloon pump should be preceded by examination of the descending aorta to rule out severe atherosclerotic changes, in which case alternative cardiac support should be attempted.

Gastroprotective Strategies in Chronic NSAID Users: A Cost-Effectiveness Analysis Comparing Single-Tablet Formulations with Individual Components

ObjectivesTo evaluate the cost-effectiveness of competing gastroprotective strategies, including single-tablet formulations, in the prevention of gastrointestinal (GI) complications in patients with chronic arthritis taking nonsteroidal anti-inflammatory drugs (NSAIDs). MethodsWe performed a cost-utility analysis to compare eight gastroprotective strategies including NSAIDs, cyclooxygenase-2 inhibitors, proton pump inhibitors (PPIs), histamine-2 receptor antagonists, misoprostol, and single-tablet formulations. We derived estimates for outcomes and costs from medical literature. The primary outcome was incremental cost per quality-adjusted life-year gained. We performed sensitivity analyses to assess the effect of GI complications, compliance rates, and drug costs. ResultsFor average-risk patients, NSAID + PPI cotherapy was most cost-effective. The NSAID/PPI single-tablet formulation became cost-effective only when its price decreased from €0.78 to €0.56 per tablet, or when PPI compliance fell below 51% in the NSAID + PPI strategy. All other strategies were more costly and less effective. The model was highly sensitive to the GI complication risk, costs of PPI and NSAID/PPI single-tablet formulation, and compliance to PPI. In patients with a threefold higher risk of GI complications, both NSAID + PPI cotherapy and single-tablet formulation were cost-effective. ConclusionsNSAID + PPI cotherapy is the most cost-effective strategy in all patients with chronic arthritis irrespective of their risk for GI complications. For patients with increased GI risk, the NSAID/PPI single-tablet formulation is also cost-effective.