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Anti-inflammatory drugs

Small ulcer resulting from anti-inflammatory drugs
Anti-inflammatory drugs cause ulcers

What are the risks of anti-inflammatory drugs?

  • At any one time 20% of people taking NSAIDs (non-steroidal anti-inflammatory drugs) will have a “stomach ulcer”.
    • A stomach ulcer may be silent (no symptoms) or may cause some indigestion.
    • The figure of 20% may seem high but this comes from endoscopy studies and shows that most ulcers are relatively small and do not cause symptoms
    • The most important problems are bleeding from the stomach and perforation of the stomach wall. Both complications are likely to lead to hospital admission.
  • The risk of bleeding per prescription of is very low.
    • 35 / 100,000 prescriptions if you are less than 60 years.
    • 210 / 100,000 if you are over 60 years.
    • The annual incidence of major complications for regular users is 1-2% per year.
  • Most prescriptions for anti-inflammatory drugs are given for a short period of time (1-4 weeks).
    • Therefore it is common that bleeding often occurs after taking only a few of these drugs.
    • Regular users do adapt to the drugs to a certain extent but there is still a risk at any stage.
  • The major risk factors for serious complications are;
    • Age > 70 years.
    • Female sex.
    • Past history of ulcer.
    • Anticoagulant treatment (Warfarin).
    • Steroids (prednisone).
    • Using high doses of anti-inflammatory drugs.

How can the risks be reduced?

  • There several possible approaches to reducing risk:
    • Try paracetamol only - no risks of stomach ulcer.
    • Use a lower dose (may be in combination with paracetamol).
    • Over the counter medication (OTC) is usually at a lower dose. For example Cataflam (only 25mg diclofenac) and Brufen (only 200mg ibuprofen) – both half of the commonly prescribed doses.
    • Use alternative drugs. e.g. allopurinol for treatment of gout. Methotrexate and salazopyrin for rheumatoid arthritis. Preventative drugs for migraine.
    • Treatment of Helicobacter infection. Testing for this infection can be at the time of gastroscopy or by faecal antigen test (stool sample required).  Antibiotic treatment is given for one week.
    • Choosing an anti-inflammatory with a better safety profile.
    • There are differences between NSAIDs.  The  risk of gastro-intestinal bleeding is 2-3x for brufen (Nurofen), 4x for diclofenac (Voltaren, Apo-Diclo, Flameril) and Naprosyn (Synflex, Naproxen), 6 -10x for indomethacin (Indocid).
    • Therefore Nurofen is probably the safest - diclofenac (Voltaren) is OK.
    • Rectal forms of NSAIDs have limited potential to reduce the risk of bleeding because the main action of these drugs is systemic not a direct effect on the stomach.
    • Rectal bleeding can occur with suppositories because of rectal ulcers
  • Taking “stomach protective” medication as well as the anti-inflammatory drug.
    • It used to be common practice to prescribe Zantac or Famotidine in addition to the NSAID however these drugs have limited protective effects on the stomach.
    • Misoprostol (Cytotec) has proven gastro-protective effects. This drug has side-effects of diarrhoea and abdominal cramps. These side-effects have limited the use of this drug and it is no longer available in NZ.
    • Proton pump inhibitors (Losec / omeprazole and Somac / pantoprazole) have a proven role. They are the most widely used drugs to prevent ulcer complications.
    • They reduce, but do not take away completely, the risk of a complication such as bleeding or perforation (about 50% reduction in risk).
    • If there are risk factors present or if there has been a complication in the past then there is definitely still a risk even with these drugs.
    • These medications can improve nausea or indigestion that may come with taking NSAIDs. However some people continue to have nausea when taking anti-inflammatory drugs even with use of Losec or similar drugs.

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