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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

GI risks of selective and non-selective NSAIDs

A paper has been published in Gut reporting the findings of an observational study conducted in Spain examining patients with endoscopically confirmed upper gastrointestinal (GI) bleeds.

The study aimed to identify associations between bleed risk and the use of coxibs, standard NSAIDs, aspirin or combinations of these drugs.

Some of the key findings include:

  • No increase in bleed risk in those patients using concomitant proton pump inhibitors (PPIs)
  • Reduced bleed risk with coxibs is removed by concomitant use of low-dose aspirin
  • Non-aspirin antiplatelets (clopidogrel/ticlodipine) carries a similar risk to low-dose aspirin

These findings are based on real life use of these drugs rather than clinical trials where certain patients are excluded. The increased bleed risk seen with non-aspirin antiplatelets may be due to an increased baseline risk in those particular individuals. This study highlights that in higher risk patients, where more cautious treatments are used, vigilance should be maintained.

This study found that use of low-dose aspirin negates the gastro-protective qualities of coxibs. It also appears to show that PPIs provide adequate protection from GI bleeds. It would seem prudent to use PPI protection in patients who are at risk of a GI bleed but who still require treatment with an NSAID, especially in combination with low-dose aspirin. In such patients there is no reason to prescribe a coxib over a standard NSAID.

Action: As stated before, prescription of NSAIDs involves an assessment of GI, cardiovascular and renal risk. In patients at high-risk of a GI bleed where NSAID treatment is absolutely necessary PPIs appear to provide gastroprotection.

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