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Primer: managing NSAID-induced ulcer complications—balancing gastrointestinal and cardiovascular risks

Abstract

Ulcer complications associated with the use of NSAIDs, in high-risk patients, are often caused by a failure to identify patients' risk factors, concomitant use of aspirin or multiple NSAIDs, and underutilization of gastroprotective agents. Current data suggest that cyclo-oxygenase 2 (COX2) inhibitors and some nonselective NSAIDs increase the risk of myocardial infarction. Physicians must, therefore, take into account both the gastrointestinal and the cardiovascular risks of individual patients when prescribing NSAIDs. In patients with a low cardiovascular risk, NSAIDs can be prescribed according to the level of gastrointestinal risk. Patients with a moderate gastrointestinal risk (one or two risk factors) should receive a COX2 inhibitor or an NSAID plus a PPI or misoprostol. Patients with more than two gastrointestinal risk factors or prior ulcer complications require the combination of a COX2 inhibitor and a PPI. Patients with a high cardiovascular risk (e.g. coronary heart disease or an estimated 10-year cardiovascular risk greater than 10%) should receive prophylactic aspirin and combination therapy with a PPI or misoprostol irrespective of the presence of gastrointestinal risk factors. Naproxen is the preferred NSAID because it is not associated with excess cardiovascular risk. Patients with a high cardiovascular risk and a very high gastrointestinal risk should avoid using NSAIDs or COX2 inhibitors.

Key Points

  • NSAID-induced ulcer complications can be avoided by careful assessment of risk factors before prescription of these drugs

  • In light of the potential cardiovascular risk of COX2-selective and nonselective NSAIDs, physicians must evaluate both the gastrointestinal and the cardiovascular risk profiles of individual patients when prescribing NSAIDs

  • COX2 inhibitors alone, or nonselective NSAIDs plus a PPI, do not provide adequate gastric protection to patients with a very high gastrointestinal risk

  • Physicians can assess the cardiovascular risk of individual patients by use of the Framingham risk-score calculator

  • Patients with a high cardiovascular risk who require NSAIDs should receive prophylactic aspirin and combination therapy with a PPI or misoprostol

  • Naproxen is the preferred NSAID in patients with high cardiovascular risk

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Figure 1: Cumulative incidence of ulcers within 6 months of initiating treatment with celecoxib or diclofenac plus omeprazole in patients with prior ulcer bleeding.

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Chan, F. Primer: managing NSAID-induced ulcer complications—balancing gastrointestinal and cardiovascular risks. Nat Rev Gastroenterol Hepatol 3, 563–573 (2006). https://doi.org/10.1038/ncpgasthep0610

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