Primer: managing NSAID-induced ulcer complications--balancing gastrointestinal and cardiovascular risks

Ulcer complications associated with the use of NSAIDs, in high-risk patients, are often caused by a failure to identify patients' risk factors, concomitant use of aspirin or multiple NSAIDs, and underutilization of gastroprotective agents. Current data suggest that cyclo-oxygenase 2 (COX2) inhibitors and some nonselective NSAIDs increase the risk of myocardial infarction. Physicians must, therefore, take into account both the gastrointestinal and the cardiovascular risks of individual patients when prescribing NSAIDs. In patients with a low cardiovascular risk, NSAIDs can be prescribed according to the level of gastrointestinal risk. Patients with a moderate gastrointestinal risk (one or two risk factors) should receive a COX2 inhibitor or an NSAID plus a PPI or misoprostol. Patients with more than two gastrointestinal risk factors or prior ulcer complications require the combination of a COX2 inhibitor and a PPI. Patients with a high cardiovascular risk (e.g. coronary heart disease or an estimated 10-year cardiovascular risk greater than 10%) should receive prophylactic aspirin and combination therapy with a PPI or misoprostol irrespective of the presence of gastrointestinal risk factors. Naproxen is the preferred NSAID because it is not associated with excess cardiovascular risk. Patients with a high cardiovascular risk and a very high gastrointestinal risk should avoid using NSAIDs or COX2 inhibitors.