A clinical approach to management of patients with non-steroidal anti-inflammatory gastropathy

The treatment of a peptic ulcer occurring in a patient who is taking non-steroidal anti-inflammatory drugs depends on whether or not the patient can readily stop taking the non-steroidal anti-inflammatory drug. If they can, healing is generally rapid, and can be achieved with any effective ulcer-healing agent. When the non-steroidal anti-inflammatory drug cannot be easily stopped, ulcer healing is slower and the treatment of choice is to heal the ulcer with a proton pump inhibitor. The risk of ulceration in patients taking non-steroidal anti-inflammatory drugs can be reduced by two main strategies: the choice of non-steroidal anti-inflammatory drug and its dosage on the one hand, and the use of prophylactic co-therapy on the other. The two are not of course mutually exclusive. It is now clear that not all non-steroidal anti-inflammatory drugs are equally damaging. Several studies have shown that the shorter half life drugs (at least in their recommended dosages) are generally less ulcerogenic. There is clear dose-dependence, so the drugs should be used at the lowest effective dose, and non-steroidal anti-inflammatory drugs should not be given in combination without careful weighing of risks and benefits. Giving either omeprazole or misoprostol concurrently with a non-steroidal anti-inflammatory drug substantially reduces the risk of ulceration. Full dosage histamine H2-receptor antagonists give good protection against non-steroidal anti-inflammatory drug-associated duodenal ulcers, but two large trials with ranitidine showed no protection against gastric ulcer. One study of double dosage famotidine did show a reduction in gastric ulcer incidence as well. Recently, two large randomized trials have compared omeprazole 20 mg daily head-to-head with ranitidine and misoprostol. Overall, the proton pump inhibitor was more effective than the other two for ulcer prevention, although it is interesting that erosions seemed to be prevented better by the prostaglandin. The biggest challenge for clinical judgement is when to use prophylactic co-therapy. Patients for whom this should be especially considered are those who have had a prior ulcer, the elderly, those needing higher non-steroidal anti-inflammatory drug dosage or co-therapy with vascular-protective aspirin, and those whose other medical conditions make them less likely to survive a gastrointestinal haemorrhage or perforation.