Review article: recommendations for the clinical management of patients taking non-steroidal anti-inflammatory drugs – a gastroenterologist's perspective

There are several risk factors that predispose a patient taking non-steroidal anti-inflammatory drugs to an increased risk of upper gastrointestinal bleeding. The most significant are a previous ulcer history and age, but other factors such as non-steroidal anti-inflammatory drug dose, concomitant aspirin and Helicobacter pylori infection also play a role.

When giving non-steroidal anti-inflammatory drug treatment the physician must balance the known benefits in terms of a reduction in pain and inflammation, and in the case of aspirin the cardiovascular benefits, with the potential gastrointestinal risks, which can be fatal. Selective cyclo-oxygenase-2 inhibitors have similar efficacy to non-selective non-steroidal anti-inflammatory drugs but a better gastrointestinal safety profile, and were an attractive alternative to traditional non-steroidal anti-inflammatory drugs until recent data raised concerns about their cardiovascular safety.

It has also been demonstrated that the gastrointestinal benefits of cyclo-oxygenase-2 agents are eliminated when they are taken concomitantly with aspirin. A Spanish epidemiological study investigated the relative risk of upper gastrointestinal bleeding with cyclo-oxygenase-2 inhibitors and a range of other non-steroidal anti-inflammatory drugs. The combination of a non-steroidal anti-inflammatory drug plus a proton-pump inhibitor was found to reduce the risk of gastrointestinal bleeding; the combination of a cyclo-oxygenase-2 agent plus a proton-pump inhibitor further reduced this risk, and was calculated to be a cost-effective option compared with hospitalization for a gastrointestinal bleeding event.