www . specialistforum . co . za
PAIN
PPIs for NSAIDs induced gastropathy
NSAID induced gastropathy can result from any dose or any frequency intake of NSAID drugs as well as long-term use . These drugs are used to decrease pain and inflammation and are often taken by those diagnosed with osteoarthritis and rheumatoid arthritis or other musculoskeletal conditions . NSAIDs are often prescribed to these individuals , as well as suggested as over the counter ( OTC ) types of NSAIDs . Because of the easy accessibility of these drugs , the incidence rate of NSAID induced gastropathy is high , especially among individuals who are > 60 years . The small and large bowel can also be affected .
NSAID induced gastropathy can result in stomach or duodenal ulcers which may even lead to death . There are thousands of hospitalisations over each year just from symptoms resulting from NSAID use . Though these rates are high , most individuals do not know the risk of these medications and continue to take them . Also , this induced gastropathy goes on asymptomatically until it is too late and has caused further damage of the gastrointestinal tract .
NSAIDs are COX-1 inhibitors which suppress the mucous barrier in the gastrointestinal system which can lead to break down of the GI tract as well as increase in the acidity of the gastric contents .
The mechanism of action and injury of the NSAIDs is caused by interfering with the archidonic acid pathway ( prostaglandins ).
Gastrointestinal effects of aspirin
Aspirin is being used as an effective analgesic and anti-inflammatory agent at doses > 325 mg daily . At low doses ( 75-325 mg daily ), aspirin is the key antiplatelet drug in the pharmacological prevention of cardiovascular diseases . However , topical and systemic effects of aspirin in the gastrointestinal mucosa are associated with mucosal damage in the upper and lower gastrointestinal tract . The risk of upper gastrointestinal bleeding with aspirin is increased with old age , male sex , ulcer history and concomitant medication with NSAIDs , cyclooxygenase 2 selective inhibitors , corticosteroids or other antithrombotic agents . In some patients , the cardiovascular benefits of low-dose aspirin might be overcome by the risk of gastrointestinal complications , but withdrawal of aspirin therapy can precipitate a cardiovascular event . These patients will need concomitant therapy with antisecretory agents , especially PPIs , to reduce the gastrointestinal risk . Eradication of Helicobacter pylori infection might be an additional option in patients with a history of ulcer . Furthermore , there is growing evidence that longterm use of aspirin decreases the risk of colorectal cancer , even at low doses . As aspirin is one of the most prescribed drugs worldwide and its clinical impact is huge , physicians need to consider the benefits and harms for each individual patient in order to maximise the benefits of aspirin .
Treatment results : RCTs
Omeprazole , the most extensively studied PPI , has a protective effect against NSAID-related mucosal injury . Not unexpectedly , because of its potent acid-inhibiting property , it prevents DU in patients taking NSAIDs . There is evidence that omeprazole also protects against GU . In a crossover , double-blind RCT , 20 normal volunteers were given aspirin 650 mg q . i . d . with either placebo or omeprazole 40 mg / day for 14 days , with endoscopy before and after each treatment period . Omeprazole significantly decreased aspirin-induced gastric mucosal injury ( p < 0.01 ) by protecting 85 % of the subjects from extensive erosions or ulcer , whereas 70 % of the subjects developed severe injury ( rate 3 or 4 on 0-4 scale ) on aspirin and placebo . No duodenal injury was seen in any grade or any subject on omeprazole , whereas 50 % on placebo developed erosions and 15 % had DU ( p < 0.001 ).
Three large RCTs have been carried out in patients with OA and RA comparing omeprazole with placebo , misoprostol , and ranitidine for the prevention of GU and DU . Overall , omeprazole significantly reduced the total number of NSAIDrelated ulcers when compared with placebo and ranitidine . It was more effective than misoprostol in preventing DU , and equally so in reducing GU . It should be noted that the lowest effective dose of misoprostol was used in this study , and that most of the overall prevention in NSAID-related ulcer in the placebo-controlled studies was due to a reduction in the numbers of duodenal ulcers .
Recently , esomeprazole has been used in RCTs , as it has superiority to omeprazole , in terms of acid inhibition .
PPIs for NSAID-associated symptoms and lesions
A recent review , Effective and safe proton pump
Nonsteroidal antiinflammatory drugs ( NSAIDs ) constitute a well-known group of drugs that are most widely used for a variety of inflammatory conditions and pain . However , their gastrointestinal side effects , hamper their usefulness in many clinical settings .
Reviewed by Professor Reid Ally A specialist Gastroenterologist and appointed adjunct Professor of Medicine in 2001 . Currently he is the Head of Gastroenterology ( Wits ) and Chris Hani Baragwanath Hospital and senior lecturer and teacher of diagnostic and interventional endoscopy .
The Specialist Forum | Vol . 17 No . 4
May 2017 | 23