Review article: low-dose aspirin, non-steroidal anti-inflammatory drugs and cyclo-oxygenase inhibitors – balancing risks and benefits

In recent years, there has been a rapid increase in the number of patients using aspirin for the prevention of cardiovascular events and also other non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, for the treatment of arthritis. However, aspirin and non-steroidal anti-inflammatory drugs are associated with an increase in gastrointestinal risk. Recent studies have shown that cyclo-oxygenase-2 inhibitors, and possibly non-selective non-steroidal anti-inflammatory drugs, increase the cardiovascular risk.

In patients taking aspirin, the ‘gold standard’ therapy to reduce gastrointestinal risk is concomitant therapy with a gastroprotective agent, such as a proton-pump inhibitor. Other gastroprotective agents, such as misoprostol, while equally effective may be associated with a higher proportion of adverse events. Helicobacter pylori infection has been shown to increase the risk of upper gastrointestinal bleeding associated with low-dose aspirin. Emerging data suggest that the eradication of H. pylori reduces the gastrointestinal risk of high-risk aspirin users. Other antiplatelet agents such as clopidogrel that were thought to be non-ulcerogenic have been widely used as alternatives to aspirin. However, recent studies have shown that clopidogrel induces an unacceptably high rate of ulcer bleeding in high-risk patients.

When prescribing non-steroidal anti-inflammatory drugs therapy, treatment needs to be individualized according to the patients’ gastrointestinal and cardiovascular risk factors.