NSAID GastropathyNSAID Gastropathy

Group B Lim, Imee – Lim, Mary

NSAIDSNSAIDS

• Weak organic acids that inhibit biosynthesis of prostaglandins

• Anti-inflammatory, analgesic, antipyretic, antiplatelet effects

• Ex: Aspirin, Ibuprofen

ProstaglandinProstaglandin

• Regulate the release of mucosal bicarbonate and mucus

• Inhibit parietal cell secretion• Important in maintaining mucosal blood flow• Epithelial cell restitution

Symptoms:Symptoms:

• Epigastric pain (burning or gnawing)– Ill-defined, aching sensation, hunger pain– DU: 90min-3hrs after meals

Relieved by antacids or food• Pain that awakes the patient from sleep

– GU: pain precipitated by foodacid-induced activation of chemical receptors in the

duodenumenhanced duodenal sensitivity to bile acids and

pepsinor altered gastroduodenal motility

• Complications– Variation in intensity or distribution of pain as well

as onset of associated symptoms– Penetrating Ulcer:

• Dyspepsia that is no longer relieved by food or antacids and radiates to the back

– Bleeding:• Tarry stool, coffee ground emesis

– Perforation:• Severely tender, board-like abdomen• Sudden onset of severe generalized abdominal pain

– Gastric outlet obstruction• Pain worsening with meals, nausea and vomiting • Presence of succussion splash

Risk FactorsRisk Factors

• Advanced age• History of ulcer• Concomitant use of glucocorticoids• High dose or multiple NSAIDS• Concomitant of use anticoagulants• Serious or multisystem disease

Diagnosis

- Screening for Aspirin or NSAIDs in Blood and urine

Treatment

• Goals of therapy - Treatment of active ulcer- Prevention of future injury

Harrison's Principles of Internal Medicine 17th Ed

Recommendation for Treatment of NSAID related mucosal injury

Clinical Setting Recommendation

Active ulcer

NSAID discontinued

NSAID continued

H2 receptor antagonist or PPI

PPI

Prophylactic therapy Misoprostol

PPI

Selective COX-2 inhibitor

H. Pylori infection Eradication if active ulcer is present or there is a past history of peptic ulcer disease

Harrison's Principles of Internal Medicine 17th Ed

Guide to NSAID TherapyNo/ Low NSAID GI Risk NSAID GI Risk

No CV risk

(no Aspirin)

Traditional NSAID Coxib or Traditional NSAID + PPI

Consider non-NSAID therapy

CV risk

(consider Aspirin)

Traditional NSAID + PPI if GI risk warrants gastroprotection

Consider non-NSAID therapy

A gastroprotective agent must be added if a traditional NSAID is prescribed

Consider non-NSAID therapy

Prevention of NSAID induced Ulceration

• H2 receptor antagonist• Misoprostol • PPI

NSAID gastropathy

• Patient’s history of taking diclofenac Na with concomitant use of clopidogrel

• Patient’s advanced age (65 years old)• Bleeding as complication of NSAID-induced

disease