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Prevention of NSAID-related upper gastrointestinal toxicity: a meta-analysis of traditional NSAIDs with gastroprotection and COX-2 inhibitors.

Rostom A, Muir K, Dube C, Lanas A, Jolicoeur E, Tugwell P - Drug Healthc Patient Saf (2009)

Bottom Line: Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers.Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses.Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs.

View Article: PubMed Central - PubMed

Affiliation: University of Calgary, Calgary, Alberta, Canada;

ABSTRACT

Background: Traditional NSAIDs (tNSAIDs) and COX-2 inhibitors (COX-2s) are important agents for the treatment of a variety or arthritic conditions. The purpose of this study was to systematically review the effectiveness of misoprostol, H2-receptor antagonists (H2RAs), and proton pump inhibitors (PPIs) for the prevention of tNSAID related upper gastrointestinal (GI) toxicity, and to review the upper gastrointestinal (GI) safety of COX-2s.

Methods: An extensive literature search was performed to identify randomized controlled trials (RCTs) of prophylactic agents used for the prevention of upper GI toxicity, and RCTs that assessed the GI safety of the newer COX-2s. Meta-analysis was performed in accordance with accepted techniques.

Results: 39 gastroprotection and 69 COX-2 RCTs met inclusion criteria. Misoprostol, PPIs, and double doses of H2RAs are effective at reducing the risk of both endoscopic gastric and duodenal tNSAID-induced ulcers. Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers. Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses. COX-2s are associated with fewer endoscopic ulcers and clinically important ulcer complications, and have fewer treatment withdrawals due to GI symptoms than tNSAIDS. Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs. In high risk GI patients, tNSAID with a PPI or a COX-2 alone appear to offer similar GI safety, but a strategy of a COX-2 with a PPI appears to offer the greatest GI safety.

Conclusion: Several strategies are available to reduce the risk of upper GI toxicity with tNSAIDs. The choice between these strategies needs to consider patients' underlying GI and cardiovascular risk.

No MeSH data available.


Related in: MedlinePlus

H2RAs compared to placebo for the prevention of duodenal ulcer. Analysis by dose in studies of 12 weeks or longer duration.
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f4-dhps-1-047: H2RAs compared to placebo for the prevention of duodenal ulcer. Analysis by dose in studies of 12 weeks or longer duration.

Mentions: Three RCTs with 298 patients assessed the efficacy of double dose H2RA for the prevention of tNSAID induced upper GI toxicity.47,52,53 Double-dose H2RAs when compared to placebo were associated with a statistically significant reduction in the risk of both duodenal (RR 0.26; 95% CI 0.11 to 0.65) and gastric ulcers (RR 0.44; 95% CI 026 to 0.74). This 56% relative risk reduction in gastric ulcer corresponds to a 12% absolute risk difference (from 23.1% to 11.3%) (Figures 3 and 4). Analysis of the secondary prophylaxis studies alone yielded similar results.


Prevention of NSAID-related upper gastrointestinal toxicity: a meta-analysis of traditional NSAIDs with gastroprotection and COX-2 inhibitors.

Rostom A, Muir K, Dube C, Lanas A, Jolicoeur E, Tugwell P - Drug Healthc Patient Saf (2009)

H2RAs compared to placebo for the prevention of duodenal ulcer. Analysis by dose in studies of 12 weeks or longer duration.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3108684&req=5

f4-dhps-1-047: H2RAs compared to placebo for the prevention of duodenal ulcer. Analysis by dose in studies of 12 weeks or longer duration.
Mentions: Three RCTs with 298 patients assessed the efficacy of double dose H2RA for the prevention of tNSAID induced upper GI toxicity.47,52,53 Double-dose H2RAs when compared to placebo were associated with a statistically significant reduction in the risk of both duodenal (RR 0.26; 95% CI 0.11 to 0.65) and gastric ulcers (RR 0.44; 95% CI 026 to 0.74). This 56% relative risk reduction in gastric ulcer corresponds to a 12% absolute risk difference (from 23.1% to 11.3%) (Figures 3 and 4). Analysis of the secondary prophylaxis studies alone yielded similar results.

Bottom Line: Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers.Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses.Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs.

View Article: PubMed Central - PubMed

Affiliation: University of Calgary, Calgary, Alberta, Canada;

ABSTRACT

Background: Traditional NSAIDs (tNSAIDs) and COX-2 inhibitors (COX-2s) are important agents for the treatment of a variety or arthritic conditions. The purpose of this study was to systematically review the effectiveness of misoprostol, H2-receptor antagonists (H2RAs), and proton pump inhibitors (PPIs) for the prevention of tNSAID related upper gastrointestinal (GI) toxicity, and to review the upper gastrointestinal (GI) safety of COX-2s.

Methods: An extensive literature search was performed to identify randomized controlled trials (RCTs) of prophylactic agents used for the prevention of upper GI toxicity, and RCTs that assessed the GI safety of the newer COX-2s. Meta-analysis was performed in accordance with accepted techniques.

Results: 39 gastroprotection and 69 COX-2 RCTs met inclusion criteria. Misoprostol, PPIs, and double doses of H2RAs are effective at reducing the risk of both endoscopic gastric and duodenal tNSAID-induced ulcers. Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers. Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses. COX-2s are associated with fewer endoscopic ulcers and clinically important ulcer complications, and have fewer treatment withdrawals due to GI symptoms than tNSAIDS. Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs. In high risk GI patients, tNSAID with a PPI or a COX-2 alone appear to offer similar GI safety, but a strategy of a COX-2 with a PPI appears to offer the greatest GI safety.

Conclusion: Several strategies are available to reduce the risk of upper GI toxicity with tNSAIDs. The choice between these strategies needs to consider patients' underlying GI and cardiovascular risk.

No MeSH data available.


Related in: MedlinePlus