Gastroenterology and Hepatology


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25% of chronic NSAIDs users will develop ulcer, especially in the first 3 months

2 -4% will bleed of perforate

Therefore it is important to  identify high risk patients and institute strategies to prevent ulcers


Age > 65 y.o. (OR 4.7)

Higher NSAID dose (OR 8)

H/O NSAID < 1 month (OR 7.2)

Concurrent steroid (OR 4.4)

Concurrent anticoagulants (OR 12.7)

Prior PUD (OR 2.29)

Prior GIB (OR 2.56)

ASA (RR 2-4)

H. pylori:

PUD risk with underlying H. pylori alone (increased by a factor of 1.79), NSAID (4.85), HP + NSAID (6.13)

PPI + ASA is better than HP eradication alone

After HP eradication, PPI + ASA is better than ASA alone

Prevention by Mucosal Protection:

Co-therapy with PPI addition

H2RA (Can prevent DU but NSAID GU not so well)

Synthetic PG E1 analog

Substitute with COX2 (reduce NSAID PUD but doesn’t prevent NSAID PUD, also has CV risk)

Doesn’t work: Sucralfate / Enteric coating NSAIDs

Risk Factors for NSAID GI toxicity:

High Risk:

H/O previously complicated ulcer,especially if recent

>2 RF

Moderate Risk:

Age > 65

High risk NSAID therapy

H/O previously uncomplicated ulcer

Concurrent use of ASA, steroids or anticoagulation

Low Risk:
No risk Factor

Note: H. pylori is an independent and additive risk factor and needs to be addressed.

Recommendation for prevention of NSAID related ulcer complications:

GI Risk:




Low CV Risk

NSAID alone

NSAID + PPI / Misoprostol

COX2 + PPI / Miso

Alternative rx if possible

High CV Risk (ASA)

Naproxen + PPI / Misoprostol

Naproxen + PPI / Misoprostol

Avoid NSAIDs / COX2

Use Alternative rx

edited 19th July 2010