Primary prevention of NSAID-induced ulcers

The general principles for limiting ulcer and bleeding risk with nonsteroidal anti-inflammatory drug (NSAID) use are to:

• minimise NSAID use by using alternative analgesics and physical therapies
• use the lowest possible dose of a shorter-acting NSAID for as short a time as possible
• use a cyclo-oxygenase-2 (COX-2)–selective NSAID (eg celecoxib)—this reduces, but does not abolish, the risk of ulcer disease and complications
• in patients with a history of ulcer disease, consider testing and treating for Helicobacter pylori infection before starting regular NSAID use—eradication of H. pylori reduces the risk of ulcer and bleeding even in patients who have not had an ulcer in the past
• use a daily proton pump inhibitor (PPI) as primary prophylaxis.

For the prevention of ulcers in patients taking low-dose aspirin, see Low-dose aspirin and peptic ulcers.

Primary prophylaxis with a daily PPI reduces ulceration in patients treated with either nonselective or COX-2–selective NSAIDs, and should be considered in patients at higher risk (see Risk factors for NSAID-induced ulcers). Limited data suggest the combination of a COX-2–selective NSAID with a PPI provides the best prophylaxis against a gastrointestinal adverse event, but this must balanced against the apparent increase in cardiovascular risk with COX-2–selective NSAIDsKavitt, 2019Scheiman, 2005. Suitable PPI regimens are:

Misoprostol is rarely used to prevent NSAID-induced ulcers because it has to be taken more than once daily and has gastrointestinal adverse effects (eg diarrhoea, abdominal pain, loose stools).