Gastrointestinal adverse effects of non-steroidal anti-inflammatory drugs

NSAIDs are used extensively worldwide at a cost of billions of dollars annu-ally. Adverse side effects, especially in the gastrointestinal (GI) tract, are uncommon but cause a substantial burden of illness because of the volume of use. Important upper GI complications include dyspepsia, gastric erosions and peptic ulcers and complications such as bleeding, perforation or gastric outlet obstruction. Dyspeptic symptoms may occur without correlation to endoscopic findings. Topical injury and COX-1 inhibition resulting in gastric prostaglandin suppression are two commonly postulated mechanisms of gastroduodenal damage. Advanced age, previous peptic ulcers or ulcer complications, concomitant use of glucocorticoids or anticoagulants, and high-dose or prolonged NSAID administration are known risk factors. Prevention of adverse GI events involves use of safer NSAIDs including COX-2 inhibitors, and co-prescription of gastroprotective agents. NSAID-induced ulcers heal with proton pump inhibitors or misoprostol. The role of Helicobacter pylori eradication in NSAID ulcer prophylaxis and management is controversial. Choice of NSAIDs and gastroprotective agents should be guided by risk/benefit and cost-effectiveness assessment.