From peptic ulcer disease to NSAID gastropathy. An evolving nosology

Nonsteroidal anti-inflammatory drug (NSAID)-induced gastropathy is an important clinical entity, most commonly encountered in elderly female patients. The expanding use of NSAIDs in the elderly population has led to an increased incidence of NSAID-induced gastropathy. The risk of gastric bleeding in these patients is 7-fold higher than in the younger population. Long term NSAID therapy in the elderly is apparently associated with failure of normal gastric mucosal adaptation. Silent unidentified gastric lesions are likely to be common with long term NSAID therapy, as symptomatology does not parallel pathological progression. This gastropathy, in contrast to peptic ulcer disease, is responsive to prostaglandins and other cytoprotective agents. A new generation of prostaglandin-sparing NSAIDs (e.g. nabumetone), in addition to the older nonacetylated salicylates, may represent less gastrotoxic alternatives. Therefore, these agents may substantially reduce the risk of NSAID-induced gastropathy. The debate continues as to whether to use NSAIDs, and under which circumstances. More importantly, the cost-benefit implications and justification for concomitant therapy with gastroprotective agents cloud the picture. Currently, there is a definite consensus that NSAIDs should not be casually used on a chronic basis, especially in patients at risk for serious gastropathy complications. In all cases, where possible, gastric prostaglandin-sparing NSAIDs or nonacetylated salicylates should be used in lowest effective dosages. In special circumstances, gastroprotective co-therapy can be considered. NSAID therapy probably should not be used or continued in elderly patients with a history of bleeding ulcers or recent major gastric ulcer activity.