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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” (defined as a break in the lining of the stomach greater than 5 mm diameter.
    • 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.  Successful treatment prior to starting NSAIDS has been proven to reduce risk of complications.
    • 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.  Some of observed lower risk from using Ibuprofen may be because the dose tends to be used in relatively low doses.
    • 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 some risk even with this combination of 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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