Non-steroidal anti-inflammatory drug toxicity in the upper gastrointestinal tract

Non-steroidal anti-inflammatory drug (NSAID) toxicity in the upper gastroin testinal tract is the most common serious drug-induced toxicity reported to drug regulatory authorities. In the last two decades, the rediscovery of H . pylori, development of potent ulcer-healing drugs and specific Cox-II inh ibitors have opened new horizons in the management of NSAID toxicity. A Wor king Party composed of gastroenterologists and rheumatologists in the Asia Pacific region met in Cairns, Australia, in 1999 to review the literature a nd develop appropriate guidelines. Recommendations were made based on the l atest existing evidence. The importance of clinical events as study endpoin ts was emphasized. While differences exist between NSAIDs and aspirin, most studies have shown that advanced age, history of peptic ulcer disease, ser ious concomitant illnesses and coprescription of NSAID/aspirin with anticoa gulants and steroids are high risk factors. These patients should be consid ered for prophylactic anti-ulcer therapy. Helicobacter pylori infection may aggravate the toxicity of NSAIDs and, in selected cases, should be treated before NSAID/aspirin is prescribed. Proton pump inhibitors and misoprostol are the most promising agents in preventing gastric and duodenal ulcers. W hen NSAID/aspirin needs to be continued in patients who develop an NSAID-re lated ulcer, proton pump inhibitors offer the best healing effect. With the discovery of cyclo-oxygenase isoforms (Cox-I and Cox-II), preferential and specific Cox-II inhibitors have been developed. While early clinical data have suggested promising antiinflammatory effects and improved safety profi le in the gastrointestinal tract, several key issues on long-term safety re main unresolved. The use of potent anti-ulcer therapy, treatment of H. pylo ri infection and the development of Cox-II inhibitor will change the scenar io of NSAID/aspirin-related gastrointestinal toxicity in the next millenniu m. (C) 2000 Blackwell Science Asia Pty Ltd.