NSAID gastropathy

Etiology

• non-steroidal anti inflammatory agents (NSAIDs)
• risk factors
  • history of peptic ulcer
  • high-dose NSAID use
  • simultaneous use of multiple NSAIDs
  • age > 60 years
  • concomitant use of glucocorticoids
  • anticoagulation
  • tobacco use
  • alcohol use
  • protein malnutrition
  • female sex
  • concomitant cardiac disease
  • concomitant H pylori infection*

* controversial

Epidemiology

• 5-10% of duodenal ulcers
• 20-40% as gastric ulcers

Pathology

• occult blood loss & iron deficiency anemia

Clinical manifestations

• dyspepsia
  • NOT predictive of NSAID gastropathy
  • many patients have no antecedent dyspepsia
• peptic ulcer disease (20%)*
• acute upper GI hemorrhage or perforation (1-2%)

* 20% of patients taking NSAIDs long-term will have endoscopic evidence of gastric or duodenal ulceration

Management

• proton-pump inhibitors (standard dose) 1st line
  • prevention of peptic ulcers in patients using NSAIDs
  • can heal gastric (& probably duodenal) ulcers even while NSAID therapy is continued
  • more effective than H2-receptor antagonists
• H2-receptor antagonists
  • may decrease incidence of duodenal ulcers
  • not effective for prevention of gastric ulcers*
• misoprostol
  • 200-400 mg PO QID
  • can heal as well as prevent ulcers in most patients taking NSAIDs
  • ONLY agent with proven benefit in patients with rheumatoid arthritis
• treat concurrent H. pylori infection
• sucralfate of NO benefit
• stopping NSAID may be indicated
• a COX-2 inhibitor may be useful
• if stopping anti-inflammatory agent is not an option, the most effective strategy to prevent recurrence is use of celecoxib plus twice daily proton pump inhibitor
• restarting low-dose aspirin 3-5 days after upper GI bleed reduces 30-day mortality 10-fold in patients with cardiovascular disease, while increasing rebleeding rates only 2-fold

* one study found famotidine effective in prevention of both duodenal & gastric ulcers in patients on long-term NSAID therapy

More general terms

• gastritis
• adverse drug reaction (ADR)

Additional terms

• dyspepsia (indigestion)
• non-steroidal anti-inflammatory agent (NSAID)