Nonsteroidal anti-inflammatory drugs (
NSAIDs) produce symptoms of
dyspepsia and
peptic ulcer disease in up to 50% and up to 20%, respectively, of individuals taking them. Risk factors for
NSAID-related gastric injury include age >70 years, history of
ulcer disease, use of multiple agents (e.g., > or =2
NSAIDs, or an
NSAID plus
aspirin--even at cardioprotective doses), high doses of an
NSAID, and concurrent use of
corticosteroids or
anticoagulants. In
NSAID users,
infection with Helicobacter pylori can produce additive or synergistic gastric mucosal injury. Several clinical strategies can decrease the risk for
dyspepsia, ulceration, and the more serious complications in
NSAID users.
Proton pump inhibitor (PPI) co-
therapy has been shown to lower the incidence of
dyspepsia in those taking
NSAIDs. In those with an active
ulcer, PPI
therapy produces
ulcer healing even in "tough-to-treat" individuals who require ongoing
NSAID therapy. Maintenance of
ulcer healing is significantly greater in those who receive ongoing PPI treatment compared with placebo, and adverse events and treatment withdrawals are fewer compared with their occurrence in persons treated with
misoprostol. In those not receiving
aspirin therapy, the use of an
NSAID that is a selective inhibitor of
cyclooxygenase (COX)-2 may result in fewer gastrointestinal symptoms compared with a traditional agent; however, studies have failed to show any decrease in healthcare resource utilization (including outpatient or emergency room visits, hospitalization rate, or use of any resource) with COX-2-selective
therapy.