21 Feb 2015

Gastrointestinal toxicity of NSAIDs

NSAIDs are commonly used analgesic in clinical practise. Most commonly used NSAIDS  are aspirin, diclofenac, ibuprofen, indomethacin etc. Among these aspirin is well known to cause stomach mucosal injury. After 90 minutes taking about 300-600 mg of Aspirin almost everyone will develop minute mucosal bleeding and erosion. They are associated  with various gastro intestinal side effects such as non-ulcer dyspepsia and ulcers.
Gastro intestinal side effect of NSAIDs are given below.
Oesophageal strictures
Gastric and duodenal petechiae, erosions.
Ulceration, bleeding, and perforation.
Type C gastritis
Small and large bowel ulceration, bleeding, and perforation
Exacerbation of colitis

Diagram showing mucosal erosion.area with light colour is the normal part of mucosa and reddish part represent mucosal injury
Who is at risk for gastro intestinal side effect?
Factors related to Patient.
Age more than  60 years - Elderly are prone to toxicity because of increased prevalence of ulcer disease, they are more likely to receive NSAIDS and increased sensitivity to them.
Patients with history of ulcer disease even if not related to NSAID  are also at high risk.
Drug related factors
Relatively toxic NSAID use ibuprofen at a dose  less than <1200 mg/day is associated with a lower risk compared to other NSAIDs Azapropazone and piroxicam have higher risk. As the dose of the drug increases the side effect also increases.
High dose of NSAID (or two NSAIDs used simultaneosly)
Used with anticoagulant
Concurrent use of corticosteroid
Uncertain or possible risk factors
Prolonged duration of NSAID treatment
Female sex
Those with  rheumatic disease
Heart disease
Helicobacter pylori infection
Alcohol consumption
Management of people on NSAIDS to reduce the side effect
NSAIDS  are better avoided in those at high risk of ulceration ,if not possible they should be given prophylactic treatment.
Available drugs to treat ulcers
Patients  while on NSAIDS develop ulceration due to two reasons .Due to inhibition of prostaglandin synthesis and impairement of mucosal defence.and the acid attack will lead to frank  ulceration. Misoprostol is an analogue of prostaglandin E1. Several studies show that it prevents acute gastric injury by a wide variety of agents including NSAIDs. 400-800g daily will help to protect against NSAID  induced mucosal injury and ulceration that will help to reduce the hospitalization Side effects are diarrhoea, abdominal cramps, and reflux
Acid suppressoin - High doses of H2 antagonists and proton pump inhibitor are used.

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