Can Gastroduodenal Ulcers in NSAID Users Be Prevented?

Numerous epidemiologic and endoscopic studies have shown that regular use of prostaglandin synthesis inhibitors such as aspirin or other NSAIDs can lead to gastroduodenal [1] and intestinal ulcers [2]. It is not unusual for a regular NSAID user to have a life-threatening ulcer complication (bleeding or perforation). Among persons who ingest NSAIDs regularly, how often do clinically important ulcers occur? The answer to this important question is not yet known. It has been stated that symptomatic ulcers (that is, ulcers associated with pain or a complication such as bleeding or perforation) occur in approximately 1% of patients after use of nonsalicylate NSAIDs for 3 to 6 months and in 2% to 4% of patients after 1 year [3]. Further, no subset of patients who are not at risk for NSAID-related ulcers has been identified [3]. Can these symptomatic ulcers be prevented?

One obvious way to eliminate these serious ulcer complications is to avoid the use of NSAIDs whenever possible. In many people with mild to moderate pain or with fever, acetaminophen can be used for its analgesic or its antipyretic actions. In some patients with osteoarthritis or rheumatoid arthritis, a nonacetylated salicylate can be used as an anti-inflammatory agent. Salsalate, for example, neither inhibits prostaglandin synthesis in the gastroduodenal mucosa nor causes acute gastroduodenal mucosal injury [4]. However, both aspirin and nonsalicylate NSAIDs remain popular agents, a testimonial to their cost-effectiveness and relative safety [5]. Aspirin, for example, is effective in the prevention of myocardial infarction, occlusion of saphenous vein grafts, and strokes and in the treatment of acute myocardial infarction, unstable angina, and transient cerebral ischemic attacks [6]. Furthermore, recent epidemiologic evidence suggests that regular aspirin use may be associated with lower mortality from certain cancers, including colonic cancer [7]. Nonsalicylate NSAIDs …