Review article: prevention of non-steroidal anti-inflammatory drug gastrointestinal complications--review and recommendations based on risk assessment

Aliment Pharmacol Ther. 2004 May 15;19(10):1051-61. doi: 10.1111/j.1365-2036.2004.01935.x.


The incidence of non-steroidal anti-inflammatory drug-related ulcer complications remains high despite the availability of potent anti-ulcer drugs and selective cyclo-oxygenase-2 inhibitors. Non-steroidal anti-inflammatory drug-related ulcer complications can be minimized by prospective assessment of patients' baseline risk, rational choice and use of non-steroidal anti-inflammatory drugs, and selective use of co-therapy strategies with gastroprotectives. Current recommendations regarding strategies using anti-ulcer drugs and cyclo-oxygenase-2 inhibitors for prevention of clinical non-steroidal anti-inflammatory drug upper gastrointestinal events are largely derived from studies using surrogates such as endoscopic ulcers, erosions, and symptoms in low- to average-risk patients. Conclusions based on surrogate and potentially manipulatable end-points are increasingly suspect with regard to applicability to clinical situations. This article reviews the risks associated with non-steroidal anti-inflammatory drugs including aspirin and includes the effect of the patients' baseline risk, and the confounding effects of Helicobacter pylori infection. In addition, uncertainties regarding the clinical efficacy of anti-ulcer drugs and cyclo-oxygenase-2 inhibitors against non-steroidal anti-inflammatory drug-related ulcer complications are put into perspective. We propose management strategies based on the risk category: low risk (absence of risk factors) (least ulcerogenic non-steroidal anti-inflammatory drug at lowest effective dose), moderate risk (one to two risk factors) (as above, plus an antisecretory agent or misoprostol or a cyclo-oxygenase-2 inhibitor), high risk (multiple risk factors or patients using concomitant low-dose aspirin, steroids, or anticoagulants) (cyclo-oxygenase-2 inhibitor alone with steroids, plus misoprostol with warfarin, or plus a proton pump inhibitors or misoprostol with aspirin), and very high risk (history of ulcer complications) (avoid all non-steroidal anti-inflammatory drugs, if possible or a cyclo-oxygenase-2 plus a proton pump inhibitors and/or misoprostol). The presence of H. pylori infection increases the risk of upper gastrointestinal complications in non-steroidal anti-inflammatory drug users by two- to fourfold suggesting that all patients requiring regular non-steroidal anti-inflammatory drug therapy be tested for H. pylori.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.
  • Review

MeSH terms

  • Anti-Inflammatory Agents, Non-Steroidal / adverse effects*
  • Anti-Ulcer Agents / therapeutic use
  • Aspirin / adverse effects
  • Cyclooxygenase 2
  • Decision Making
  • Gastrointestinal Diseases / chemically induced*
  • Gastrointestinal Diseases / prevention & control
  • Helicobacter Infections / complications
  • Helicobacter pylori
  • Histamine H2 Antagonists / therapeutic use
  • Humans
  • Isoenzymes / antagonists & inhibitors
  • Membrane Proteins
  • Misoprostol / therapeutic use
  • Prostaglandin-Endoperoxide Synthases
  • Proton Pump Inhibitors
  • Risk Assessment
  • Risk Factors
  • Stomach Ulcer / complications


  • Anti-Inflammatory Agents, Non-Steroidal
  • Anti-Ulcer Agents
  • Histamine H2 Antagonists
  • Isoenzymes
  • Membrane Proteins
  • Proton Pump Inhibitors
  • Misoprostol
  • Cyclooxygenase 2
  • PTGS2 protein, human
  • Prostaglandin-Endoperoxide Synthases
  • Aspirin