english.prescrire.org > Spotlight > Archives : 2011 > Nonsteroidal anti-inflammatory drugs (NSAIDs): no routine use of anti-ulcer drugs

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Nonsteroidal anti-inflammatory drugs (NSAIDs): no routine use of
anti-ulcer drugs

When an NSAID is deemed necessary, it is better to prescribe those with the best risk-benefit balance, at the lowest effective dose and for the shortest period. Anti-ulcer drugs are only warranted when there is a serious risk of severe gastrointestinal adverse effects.

When an analgesic is required, paracetamol is the reference treatment. If an NSAID is considered appropriate, it is better to prescribe the lowest dose possible of ibuprofen or naproxen, and for the shortest possible time.

All NSAIDs expose patients to sometimes severe, even fatal, adverse effects, particularly gastrointestinal (haemorrhage, perforations, obstruction).

Patients aged over 65 and those with a history of gastrointestinal ulcers or haemorrhage are most at risk of severe gastrointestinal adverse effects. This risk is also increased with high doses of NSAIDs or with NSAIDs used in combination with certain other drugs. The risk increases tenfold with the consumption of large amounts of alcohol and tobacco.

When there is a high risk of adverse effects with  long-term NSAID treatment, it is sometimes advisable to prescribe an anti-ulcer drug, but the risk-benefit balance should be carefully weighed up, given the risk of adverse effects. Evidence shows that misoprostol provides modest efficacy, but it can cause diarrhoea and abdominal pain. Omeprazole is a reasonable alternative, even though its evaluation is not complete. When taken for long periods, it can cause mild adverse effects, or even fractures.

The use of anti-ulcer drugs must not encourage patients to increase their use of NSAIDs.

©Prescrire 1 September 2011

"Nonsteroidal anti-inflammatory drugs: add an anti-ulcer drug for patients at high risk only" Prescrire Int 2011; 20 (119): 216-219. (pdf, subscribers only)

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