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NSAID and age when should use a PPI

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The incidence of gastroduodenal ulceration may be reduced by:

  • a systematic review (1) concluded that:
    • misoprostol, COX-2 specific and selective NSAIDs, and probably proton pump inhibitors significantly reduce the risk of symptomatic ulcers
    • misoprostol and probably COX-2 specifics significantly reduce the risk of serious gastrointestinal complications, but data quality is low (1)

  • H2 antagonists appear to be an ineffective at preventing gastric ulceration (1,4)
  • in situations where NSAID treatment has to be continued in those with active peptic ulceration, a proton-pump inhibitor may be the concomitant treatment of choice (2)
  • prophylaxis is advised in subgroups of patients at a high risk of developing gastrointestinal toxicity
  • NICE suggest that a clinician should (3)

    • co-prescribe a PPI for people over 45 if using a NSAID

Notes:

  • with respect to use of NSAIDs in rheumatoid arthritis (4)
    • NICE state that:

      • analgesics should be offered (for example, paracetamol, codeine or compound analgesics) to people with RA whose pain control is not adequate, to potentially reduce their need for long-term treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase-2 (COX-2) inhibitors
      • oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time
      • when offering treatment with an oral NSAID/COX-2 inhibitor
        • first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg)
          • in either case, these should be co prescribed with a proton pump inhibitor (PPI)
      • all oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, healthcare professionals should take into account individual patient risk factors, including age
      • if a person with RA needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient
      • if NSAIDs or COX-2 inhibitors are not providing satisfactory symptom control, review the disease-modifying or biological drug regimen

Reference:

  1. Hooper L et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ 2004;329:948
  2. NICE (July 2000). Guidance on the use of proton pump inhibitors in the treatment of dyspepsia.
  3. NICE (May 2009).Low back pain - Early management of persistent non-specific low back pain
  4. NICE (February 2009). Rheumatoid arthritis- The management of rheumatoid arthritis in adults
  5. NICE (July 2001). Guidance on the use of cyclo - oxygenase (Cox) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoiod arthritis.
  6. Prescribers' Journal (1999); 39 (2): 102-8.

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