REVIEW - NSAID-associated adverse effects and acid control aids to prevent them: a review of current treatment options

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Drug Saf. 2006;29(2):119-32.

NSAID-associated adverse effects and acid control aids to prevent them: a

review of current treatment options.

AstraZeneca R & D, Molndal, Sweden. jorgen.naesdal@...

NSAIDs are central to the clinical management of a wide range of conditions.

However, NSAIDs in combination with gastric acid, which has been shown to

play a central role in upper gastrointestinal (GI) events, can damage the

gastroduodenal mucosa and result in dyspeptic symptoms and peptic lesions

such as ulceration.NSAID-associated GI mucosal injury is an important

clinical problem. Gastroduodenal ulcers or ulcer complications occur in up

to 25% of patients receiving NSAIDs. However, these toxicities are often not

preceded by indicative symptoms. Data obtained from the Arthritis,

Rheumatism, and Aging Medical Information System have shown that 50-60% of

NSAID-associated peptic ulcer cases can remain clinically silent and do not

present until complications occur. Therefore, prophylactic treatment to

prevent GI complications may be necessary in a substantial proportion of

NSAID users, especially those in groups associated with a high risk of

developing these complications.Use of cyclo-oxygenase (COX)-2 selective

NSAIDs, also known as 'coxibs', substantially reduces the incidence of upper

GI toxicities seen with non-selective NSAIDs. However, there are concerns

regarding the cardiovascular safety of coxibs. For this reason, the US FDA

recommends minimal use of coxibs and only when strictly necessary.

Additionally, rofecoxib has been removed from the US market and sales of

valdecoxib have been suspended. Furthermore, upper GI toxicities still occur

in patients receiving coxibs. Therefore, cotherapies are required to prevent

and/or heal upper GI effects associated with NSAID use. Effective

prophylactic and treatment strategies include misoprostol, histamine H(2)

receptor antagonists and proton pump inhibitors (PPIs). The key role that

gastric acid plays in upper GI adverse events among NSAID users suggests

that it is important to choose the most effective agent for acid control to

alleviate symptoms, heal mucosal erosions and improve the reduced quality of

life in this patient population. PPIs provide effective acid suppression,

which is essential to avoid GI mucosal injury, and they are, therefore,

capable of dramatically decreasing the morbidity and mortality associated

with this disorder.Since many serious GI complications are not heralded by

any previous symptoms, physicians need to be aware of risk factor profiles

that predispose patients to serious GI problems. Physicians also need to

initiate the appropriate preventative acid suppressive therapy to minimise

the burden of NSAID-associated GI adverse effects.

PMID: 16454539

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