Nonsteroidal anti-inflammatory drug enteropathy
The adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the upper gastrointestinal tract are well documented. NSAIDs (including low-dose aspirin) can also adversely affect the small and large intestine, leading to occult gastrointestinal bleeding and iron-deficiency anaemia, and rarely, protein-losing enteropathy. NSAID enteropathy includes diaphragm-like strictures, ulceration, erosions and mucosal inflammation, which can affect all levels of the small bowel.
NSAID enteropathy may be suspected in a patient taking an NSAID who presents with unexplained iron-deficiency anaemia, malnutrition or recurrent abdominal painSrinivasan, 2017.
Increased rates of small bowel mucosal ulceration in patients taking nonselective NSAIDs have been reported. Studies using video capsule examination of the small bowel suggest that both nonselective and cyclo-oxygenase-2 (COX-2)–selective NSAIDs are associated with an increased risk of mucosal breaks; however, the risk is greater with nonselective NSAIDs.
Case-controlled studies suggest an increased rate of lower gastrointestinal bleeding and perforation in patients taking aspirin and other nonselective NSAIDs. Randomised controlled trials suggest these lower gastrointestinal complications may occur at the same rate in patients taking COX-2–selective NSAIDs as those taking some nonselective NSAIDsSrinivasan, 2017.
Data on preventing NSAID enteropathy are lacking, although misoprostol has been reported to be beneficial. Proton pump inhibitors and H2-antagonists do not protect the small bowel from NSAID-induced injury.
In patients with confirmed NSAID enteropathy, assess the need for ongoing NSAID therapy and stop if possible. These patients should be strongly advised to avoid NSAIDs in the future (including over-the-counter and combination preparations).