Gastrointestinal injury associated with NSAID use: a case study and review of risk factors and preventative strategies

Abstract

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective anti-inflammatory and analgesic agents and are among the most commonly used classes of medications worldwide. However, their use has been associated with potentially serious dose-dependent gastrointestinal (GI) complications such as upper GI bleeding. GI complications resulting from NSAID use are among the most common drug side effects in the United States, due to the widespread use of NSAIDs. The risk of upper GI complications can occur even with short-term NSAID use, and the rate of events is linear over time with continued use. Although gastroprotective therapies are available, they are underused, and patient and physician awareness and recognition of some of the factors influencing the development of NSAID-related upper GI complications are limited. Herein, we present a case report of a patient experiencing a gastric ulcer following NSAID use and examine some of the risk factors and potential strategies for prevention of upper GI mucosal injuries and associated bleeding following NSAID use. These risk factors include advanced age, previous history of GI injury, and concurrent use of medications such as anticoagulants, aspirin, corticosteroids, and selective serotonin reuptake inhibitors. Strategies for prevention of GI injuries include anti-secretory agents, gastroprotective agents, alternative NSAID formulations, and nonpharmacologic therapies. Greater awareness of the risk factors and potential therapies for GI complications resulting from NSAID use could help improve outcomes for patients requiring NSAID treatment.

Keywords: GI bleed; NSAID; gastrointestinal; side effects; ulcer.

Figure 1

Endoscopic image of a 1×1 cm hemorrhagic gastric ulcer in the antrum with a visible vessel revealed by endoscopy. Note: Endoscopy is from a 53-year-old woman presenting to the emergency department following two bouts of hematemesis and a melenic stool.

Figure 2

Incidence of UGI complications with increasing duration of NSAIDs in the MUCOSA and VIGOR trials. Notes: The MUCOSA trial (A) evaluated the effects of misoprostol- co-administration with a variety of nonselective NSAIDs (eg, naproxen, ibuprofen, diclofenac, and others) on gastrointestinal complication rates. Reproduced from Silverstein FE, Graham DY, Senior JR, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995;123(4): 241–249. The VIGOR trial (B) compared the gastrointestinal effects of naproxen and rofecoxib overtime. Reproduced from N Engl J Med, Bombardier C, Laine L, Reicin A, et al; VIGOR Study Group, Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group. 2000;343(21):1520–1528. Copyright ©2000 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. In both trials, the incidence of upper gastrointestinal complications with NSAIDs was began early, linear, constant, and was present for the duration of NSAID exposure. Abbreviations: MUCOSA, Misoprostol Ulcer Complication Outcomes Safety Assessment; NSAID, nonsteroidal anti-inflammatory drug; UGI, upper gastrointestinal; VIGOR, Vioxx Gastrointestinal Outcomes Research.