NSAID use in patients who have an increased risk of gastrointestinal toxicity

Australian and New Zealand College of Anaesthetists (ANZCA), 2020Kang, 2020

Patient-specific risk factors for increased gastrointestinal toxicity with NSAID use are outlined in Risk factors for NSAID-induced upper gastrointestinal bleeding or perforation. When assessing the appropriateness of using an NSAID in a patient who is at high risk of having a gastrointestinal bleed, also consider their expected prognosis if bleeding were to occur.

Avoid NSAIDs in patients with active peptic ulcer disease or gastrointestinal bleeding.

Note: Avoid NSAIDs in patients with active peptic ulcer disease or gastrointestinal bleeding.

If treatment with an NSAID is necessary for a patient with risk factor(s) for increased gastrointestinal toxicity, consider the likelihood of the NSAID to cause a serious gastrointestinal adverse effect. Factors influencing this include:

  • dose and duration of therapy—higher doses and longer courses of therapy increase the risk of a gastric ulcer and bleeding
  • half-life—NSAIDs with a longer half-life (eg piroxicam) are more likely to cause serious gastrointestinal complications
  • presence of patient-specific risk factors (see Risk factors for NSAID-induced upper gastrointestinal bleeding or perforation)
  • cyclo-oxygenase (COX)–selectivity
    • COX-2–selective NSAIDs (eg celecoxib, etoricoxib) reduce, but do not abolish, the risk of ulcer disease and complications compared with COX-1–selective NSAIDs (eg aspirin) or nonselective NSAIDs (eg diclofenac, ibuprofen).
    • Some COX-2–selective NSAIDs are only selective at low doses (eg meloxicam).
    • COX-2–selective NSAIDs do not cause fewer dyspeptic symptoms than nonselective NSAIDs.
    • The concomitant use of low-dose aspirin eliminates any upper gastrointestinal safety advantage of COX-2–selective NSAIDs.
  • concurrent Helicobacter pylori infection and NSAID use

When prescribing an NSAID to a patient with risk factor(s) for increased gastrointestinal toxicity, consider co-prescribing a proton pump inhibitor (PPI) for prophylaxis (for regimens see Preventing NSAID-induced ulcers). Limited data suggest using a COX-2–selective NSAID with a PPI provides the greatest gastrointestinal prophylaxis. For more information on prophylaxis and treatment of NSAID-induced ulcers, see NSAID-induced ulcers.

If NSAID use is likely to be long-term, provide additional encouragement for patients to address their lifestyle risk factors for gastrointestinal toxicity (eg tobacco smoking, obesity).