NSAID ulcers: prevalence and prevention

Abstract

The epidemic of life-threatening complications of nonsteroidal anti-inflammatory drug (NSAID) use has prompted the development of prevention strategies. Recent clinical trials of endoscopic ulcer prevention are critiqued regarding their results in relation to doses and outcome measures as well as H. pylori status. Misoprostol is the only agent proven to prevent life-threatening ulcer complication in NSAID users. Proton pump inhibitor therapy was not significantly better than the minimally effective dose of misoprostol for prevention of gastroduodenal ulcers in chronic NSAID users, and was significantly inferior to misoprostol in those with "true" NSAID ulcers (i.e., without complicating H. pylori infection). Antisecretory therapy accelerates corpus gastritis in those with H. pylori infection, suggesting it is prudent to consider H. pylori eradication in those in whom long term co-therapy with anti-secretory therapy is contemplated. H. pylori status is a critical variable with regard to endoscopic ulcers in NSAID users. The data suggest that if full-dose misoprostol cannot be given, the combination of an antisecretory drug (e.g., either ranitidine or omeprazole) plus low-dose misoprostol may be better than either alone for the prevention of NSAID ulcer complications. The use of omeprazole alone likely results in a false sense of security.