Defining patients at risk of non-steroidal anti-inflammatory drug gastropathy

Non-steroidal anti-inflammatory drugs have long been known to cause gastro- duodenal damage. However all parts of the gastrointestinal tract may be aff ected including the small intestine, colon and oesophagus. Non-steroidal an ti-inflammatory drugs can cause dyspeptic symptoms, erosions, ulceration, w hich may lead to haemorrhage or perforation, and a requirement for surgery. The purpose of this report is to assess risk factors which may lead to gas trointestinal damage and, thus to identify those patients at greatest risk of non-steroidal anti-inflammatory drug damage. Possible risk factors inclu de age, sex, previous ulcer history, the presence of Helicobacter pylori, t he type and severity of arthritis, individual nonsteroidal anti-inflammator y drugs (dose, duration of treatment, route of administration), other debil itating diseases, smoking, alcohol, and the use of concomitant drugs. Risk of non-steroidal anti-inflammatory drug damage is higher in older patients (RR>60 5.52; <60 1.65), but there is no convincing sex difference. There is increased risk in patients with a previous history of peptic ulceration (R R first gastrointestinal event 2.39; subsequent gastrointestinal event 4.76 ), and in the first three months of treatment. Debate continues about the r elevance of Helicobacter pylori and this will be discussed in a later repor t There is no strong evidence that patients with rheumatoid arthritis are m ore likely to have more trouble than those with osteoarthritis, but the for mer are more likely to require higher doses of non-steroidal anti-inflammat ory drugs. Highest risk non-steroidal anti-inflammatory drugs include azapr opazone, ketoprofen and piroxicam, and those with least risk include ibupro fen, diclofenac and etodolac. There is an increased risk of gastrointestina l complications with relatively small-dose prophylactic aspirin. Other fact ors increasing the risk are smoking and the presence of chronic underlying respiratory and cardiovascular disease. Risk of gastrointestinal problems i s increased with concomitant drugs, especially corticosteroids (RR 14.6 if given with non-steroidal anti-inflammatory drugs), but also with anticoagul ants and some other drugs. The clinical importance of identifying possible risk factors lies in being aware of likely problem patients and in the use of safer non-steroidal anti-inflammatory drugs or combination therapy with protective drugs in these patients.