This site is intended for healthcare professionals
Login | Register (NOW FREE)

Medical search

NSAIDs and age when should use a PPI

FREE subscriptions for doctors and students... click here
You have 3 open access pages.

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)
  • 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 (2,3)
  • prophylaxis is advised in subgroups of patients at a high risk of developing gastrointestinal toxicity (4,5)

Non-selective NSAIDs increase the risk of a GI bleed 4-fold, whereas COX-2 inhibitors increase this risk 3-fold. Co-prescription of NSAIDs with corticosteroids increases bleeding risk 12-fold, spironolactone 11-fold, and selective serotonin reuptake inhibitors (SSRIs) 7-fold (4)

  • GI bleeds while taking NSAIDs are more likely to be fatal, with a mortality of 21%, whereas in patients not taking NSAIDs it is 7% (5)

With respect to age of patient and co-prescribing proton pump inhibitors (PPIs) with a NSAID:

  • NICE CG88 suggested that a clinician should (2)
    • co-prescribe a PPI for people over 45 if using a NSAID

  • a BMJ review noted that ".. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends routine PPI co-prescription with NSAIDs for everyone aged 45 years and older with osteoarthritis, rheumatoid arthritis, or chronic low back pain" (6)

  • a BGJP review stated that "NSAIDs are readily available over the counter and patient education forms an essential part of any risk-reduction strategy with co-prescription of a proton pump inhibitor to patients >65 years or at high risk of GI complications.." (7)

  • NICE with respect to the management of osteoarthritis (8):
      • "When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg). In either case, co-prescribe with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost "

  • The American College of Gastroenterology in 2017 recommends that patients take long-term PPIs for NSAID bleeding prophylaxis if at high risk
      • Patients at high risk for ulcer-related bleeding from NSAIDs should take a PPI if they continue to take NSAIDs (9)

    • Risk factors for GI bleeding whilst on an NSAID have been stated (10):
      Age 60 years and above
      • Dyspepsia history
      • Current high dose of NSAID
      • Multiple NSAID therapy
      • Concomitant use of ASA
      • Uncomplicated peptic ulcer history
      • Concomitant use of corticosteroids
      • Concomitant use of oral anticoagulants
      • Peptic ulcer bleeding
      Helicobacter pylori infection
      • Cigarette smoking
      • Alcohol use
      • Chronic debilitating disorders, especially cardiovascular disease

A review has stated that age of >= 60 years is an indication for co-prescribing a PPI if a patient is on a NSAID (11)

So in conclusion:

  • "Various national and organisational guidance states the need for use of a PPI with a NSAIDs (based on the age of the patient) in order to reduce risk of GI bleeding. Previous NICE guidance (CG88) was specific about the age for use of co-prescribing a NSAID as if the patient was 45 years or older. More recent NICE guidance has not stated a particular age, but instead where long-term treatment with oral NSAIDs is required (such as stated in the 2018 Rheumatoid Arthritis guideline) has noted that a patient should be offered a PPI in addition to a NSAID when treating symptoms. Other guidance (10,11) has suggested an age of >= 60 years where mandatory prescribing of a PPI should be initiated when using a NSAID. The clinician must therefore consider co-prescribing a PPI when a patient is on a NSAID based on the individual patient - however NICE suggest, with reference to use of NSAIDs in patients with rheumatoid arthritis or osteoarthritis, that all patients with a NSAID prescription for symptom control should be offered a PPI to reduce the risk of GI bleeding." (12)

Notes:

  • with respect to use of NSAIDs in rheumatoid arthritis (3)
    • NICE state that:
      • consider oral non-steroidal anti-inflammatory drugs (NSAIDs, including traditional NSAIDs and cox II selective inhibitors), when control of pain or stiffness is inadequate. Take account of potential gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age and pregnancy.
      • when treating symptoms of RA with oral NSAIDs:
        • offer the lowest effective dose for the shortest possible time
        • offer a proton pump inhibitor (PPI), and
        • review risk factors for adverse events regularly
      • if a person with RA needs to take low-dose aspirin, healthcare professionals should consider other treatments before adding an NSAID (with a PPI) if pain relief is ineffective or insufficient

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 (May 2009).Low back pain - Early management of persistent non-specific low back pain (CG88)
  3. NICE (July 2018). Rheumatoid arthritis- The management of rheumatoid arthritis in adults
  4. Masclee GM et al. Risk of upper gastrointestinal bleeding from different drug combinations.Gastroenterology. 2014 Oct; 147(4):784-792.e9; quiz e13-4.
  5. Straube S et al. Mortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID use. BMC Gastroenterol. 2009 Jun 5; (9):41.
  6. Olsen AS et al.Impact of proton pump inhibitor treatment on gastrointestinal bleeding associated with non-steroidal anti-inflammatory drug use among post-myocardial infarction patients taking antithrombotics: nationwide study. BMJ 2015;351:h5096
  7. Davies A, Robson J. The dangers of NSAIDs: look both ways. Br J Gen Pract 2016 Apr; 66(645): 172–173.
  8. NICE (February 2014). Osteoarthritis: Care and Management[CG177]
  9. Freedberg DE et al. The Risks and Benefits of Long-term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017 Mar; 152(4):706-715.
  10. Gwee KA et al.Coprescribing proton-pump inhibitors with nonsteroidal anti-inflammatory drugs: risks versus benefits.J Pain Res 2018; 11: 361–374.
  11. Lain L (Editorial). NSAID-Associated Gastrointestinal Bleeding: Assessing the Role of Concomitant Medications.Gastroenterology 2014;147:730–739
  12. Editorial Comment (Dr Jim McMorran, Editor in Chief GPnotebook - August 26th 2020).

Links:

The information provided herein should not be used for diagnosis or treatment of any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions. Copyright 2016 Oxbridge Solutions LtdĀ®. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions LtdĀ® receives funding from advertising but maintains editorial independence. GPnotebook stores small data files on your computer called cookies so that we can recognise you and provide you with the best service. If you do not want to receive cookies please do not use GPnotebook.