Managing the Adverse Effects of Nonsteroidal Anti-inflammatory Drugs

Paola Patrignani; Stefania Tacconelli; Annalisa Bruno; Carlos Sostres; Angel Lanas


Expert Rev Clin Pharmacol. 2011;4(5):605-621. 

In This Article

Management of Patients With Peptic Ulcers or Dyspepsia Associated With NSAID Use

Nonsteroidal anti-inflammatory drugs and coxib therapy delay the healing of active peptic ulcers. In patients who develop a peptic ulcer during NSAID or coxib treatment, the drug should be stopped, patients treated with PPI therapy and H. pylori eradicated if the infection is present. If patients are unable to discontinue NSAID therapy, patients need to be treated with PPI twice a day co-therapy until the ulcer is healed, which must be confirmed by endoscopy.[139]

Nonsteroidal anti-inflammatory drug-associated dyspepsia is common, occurring in up to 25–50% of patients.[86,96,97] The presence of dyspepsia does not predict the presence of mucosal lesions in patients taking NSAIDs,[96,97,140] since up to 40% of persons with endoscopic evidence of erosive gastritis are asymptomatic, and conversely, as many as 50% of patients with dyspepsia have normal-appearing mucosa. COX-2-selective NSAIDs have a better GI tolerability and lower incidence of dyspepsia than non-selective NSAIDs.[141,142] Antisecretory drugs, especially PPIs, reduce the incidence of dyspepsia,[96,97] although up to 10% of patients with NSAID-induced dyspepsia will not obtain relief with antisecretory therapy.[78] In this clinical setting, two studies comparing omeprazole with ranitidine[97] or misoprostol[96] have shown that omeprazole provided greater relief of dyspeptic symptoms than ranitidine. Patients receiving the PPI reported a greater improvement in QOL than patients receiving misoprostol. The role of esomeprazole was evaluated in patients with upper GI symptoms taking NSAIDs, including COX-2 selective NSAID.[143] Esomeprazole was associated with highly significant symptom improvement compared with placebo. Esomeprazol improved symptoms in patients taking selective COX-2 NSAIDs, as well as those receiving nonselective NSAIDs. Esomeprazol was well tolerated and associated with significant improvements in QOL. Similar data were observed in a post hoc analysis of other studies that aimed to evaluate the role of esomeprazole versus placebo and versus ranitidine.[144,145]


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