Nonsteroidal Anti-inflammatory Drugs and Ulcers (cont.)
How do NSAIDs work and how do they cause stomach problems?
Prostaglandins are natural chemicals that serve as messengers
to promote inflammation. By inhibiting the body's production of prostaglandins, NSAIDs decrease inflammation. However, certain prostaglandins also are important in protecting the stomach lining from the corrosive effects of stomach acid as well as playing a role
in maintaining the natural, healthy condition of the stomach lining. These protective prostaglandins are produced by an enzyme called Cox-1. By blocking the Cox-1 enzyme and disrupting the production of prostaglandins in the stomach, NSAIDs can cause ulcers and bleeding. Some NSAIDs have less effect prostaglandins in the stomach than others, and, therefore, have a lower risk of causing ulcers.
If a stomach ulcer is detected, how is it treated?
Treatment of NSAID-induced ulcers involves
discontinuing the NSAID, reducing stomach acid with H2-blockers [for example,
ranitidine (Zantac),
cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid, Axid AR)] or, more effectively, with proton pump inhibitors,
such as omeprazole (Prilosec) or synthetic prostaglandins [misoprostol (Cytotec)]. Since
H. pylori bacteria is a common cause of ulcers,
eradication of the bacteria with a combination of antibiotics
may also promote ulcer healing.
Can NSAID-related ulcers and complications be prevented?
NSAIDs are valuable medications for patients with
inflammatory arthritis and other inflammation of body tissues.
For patients who need long-term NSAID treatment, several steps
can be taken to decrease NSAID-related ulcers and complications.
The risk of ulcers and complications tend to be dose related.
Therefore, the smallest effective dose of NSAIDs is taken to minimize
the risk. NSAIDs might be selected that have less effect on the
stomach production of prostaglandins. Some of these NSAIDs are called selective Cox-2 inhibitors. Cox-2 inhibitors block the Cox-2 enzyme that produces prostaglandins of inflammation without blocking the natural prostaglandin production of Cox-1 in the stomach
[currently in the U.S., the only available Cox-2 inhibitor is
celecoxib (Celebrex)]. Taking NSAIDs with meals may minimize stomach upset with NSAIDs but not ulcerations.
A synthetic prostaglandin, misoprostol (Cytotec),
can be administered orally along with NSAIDs. Misoprostol has
been shown to decrease NSAID-induced ulcers and their complications.
The side effects of misoprostol include abdominal cramps and
diarrhea. Misoprostol is also avoided in childbearing women because it can cause uterine muscle contractions and miscarriage. H2-blockers
and proton pump inhibitors have sometimes been used in reducing
the risk of NSAID-induced ulcers. Their effectiveness is still
under study.
Scientists are actively searching for safer NSAIDs
that are effective anti-inflammatory agents but are not ulcer
producing. In the meantime, patients who need long term NSAID
treatment should be closely supervised by a doctor. Patients at
risk of NSAID-induced ulcers and complications should consider
preventive measures, such as using NSAIDs with less stomach
prostaglandin disrupting effects, or misoprostol.
Stopping smoking, and eradicating
H. pylori may also be helpful. A variety of safer and more effective NSAIDs are available.
Last Editorial Review: 1/30/2007
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