Gastrointestinal effects of NSAIDs and coxibs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs in the world, but their use is limited because of their propensity to cause gastrointestinal (GI) injury. All patients are at risk of GI injury but certain risk factors increase the likelihood of adverse GI effects. The most important include a history of ulcer or GI complications, increasing age, concomitant anticoagulation, concomitant corticosteroid use, and high-dose NSAIDs or multiple NSAIDs (including an NSAID plus low-dose aspirin). Concurrent illness (e.g., severe rheumatoid arthritis, heart disease) has also been reported to increase the risk of GI events. NSAID-associated GI side effects markedly increase health care costs, with up to 31% of cost of managing arthritis patients accounted for through the management of GI side effects. The COX-2 specific inhibitors (coxibs) were developed with the aim of maintaining anti-inflammatory efficacy but improving gastrointestinal safety in comparison to non-selective NSAIDs. The use of COX-2 specific inhibitors significantly decreases the rate of endoscopic ulcers as compared to traditional NSAIDs. Prospective GI outcomes studies also indicate that these agents decrease clinical GI events as compared to non-selective NSAIDs. The number of patients needed to treat to avert one clinical event in one year is approximately 40-100. The cost-effectiveness of coxibs increases (the cost per GI event averted decreases) in patients with high-risk clinical features because they have higher rates of GI hospitalizations and greater use of expensive prophylactic co-therapy.