Approaches to healing and prophylaxis of nonsteroidal anti-inflammatory drug-associated ulcers

Future expectations in the prophylaxis of intestinal bleeding

Prophylaxis of gastrointestinal bleeding is attempted in widely varying situations. In NSAID-induced peptic ulcer, the advantage of selective cyclooxygenase 2 inhibitors with regard to gastrointestinal damage has yet to be translated into an advantage in overall morbidity. Strategies for primary and secondary prevention of variceal bleeding have been established. Therapy tailored to hepatic venous pressure gradient has the potential to achieve clinical relevance. Several methods have been developed to prevent postpolypectomy bleeding, but their optimal risk-tailored application has yet to be demonstrated. Although octreotide treatment seems to be beneficial in reducing the blood loss from angiodysplasias, controlled studies to determine its optimal use are awaited. Stress-ulcer prophylaxis is commonly applied in critically ill patients. Although data indicate that H2-receptor antagonists and omeprazole are effective in preventing clinically significant bleeding, evidence for an advantage with respect to length of hospital or intensive-care-unit stay, as well as mortality, is still lacking. Since there is misuse of acid-suppressing drugs on regular wards, in-house guidelines may offer the potential for saving costs and reducing inappropriate prescription.

Goal attainment in patients referred to a telephone-based dyslipidemia program

PURPOSE

Changes in low-density-lipoprotein cholesterol (LDL-C) levels and rates of LDL-C goal attainment among dyslipidemic patients newly referred to a telephone-based hyperlipidemia disease management program were studied.

METHODS

The medical records of all patients referred to a hyperlipidemia disease management program between February 2002 and May 2003 were retrospectively reviewed. Patients were included in the study if they were between 18 and 80 years of age, were under the continuous care of a physician during the data collection period, had a baseline LDL-C measurement within the year before program enrollment, and had been assigned to a treatment protocol (low- or high-risk primary prevention, secondary prevention, or diabetes). For each patient, the final cholesterol value after six months of enrollment or the first value at goal was used to evaluate response. Subjects were deemed to have reached their goal if an LDL-C value recorded within six months after enrollment corresponded to national guidelines for their assigned protocol.

RESULTS

Of 276 patients enrolled in the program, 205 were eligible for study. Forty-two patients (20.5%) were assigned to the secondary-prevention group, 69 (33.7%) to the diabetes group, 46 (22.4%) to the high-risk primary-prevention group, and 48 (23.4%) to the low-risk primary-prevention group. Overall LDL-C goals were attained by 76.2% of secondary-prevention patients, 56.5% of diabetes patients, 58.7% of high-risk primary-prevention patients, and 81.3% of low-risk primary-prevention patients.

CONCLUSION

LDL-C goal-attainment rates increased in patients referred to a telephone-based hyperlipidemia management program.

Reducing Clinically Significant Gastrointestinal Toxicity Associated with Nonsteroidal Antiinflammatory Drugs

OBJECTIVE:

To evaluate the efficacy of treatment strategies to reduce clinically significant gastrointestinal adverse effects associated with nonsteroidal antiinflammatory drugs (NSAIDs).

DATA SOURCES:

A MEDLINE search (1966–November 2003) was performed to identify relevant articles. Key search terms included proton-pump inhibitors, histamine H2 antagonists, misoprostol, cyclooxygenase-2 (COX-2) selective inhibitors, nonsteroidal antiinflammatory agents, stomach ulcer, prevention, and economics. Additional references were obtained from cross-referencing the bibliographies of selected articles.

STUDY SELECTION AND DATA EXTRACTION:

All information obtained from the MEDLINE search was reviewed. To provide the most clinically relevant information, only randomized controlled trials are included in this review.

DATA SYNTHESIS:

Clinically significant upper gastrointestinal adverse events, such as ulcers and ulcer complications, associated with NSAIDs are a cause of significant morbidity and mortality in the US. Interest in strategies to reduce the risk of these adverse events is high among clinicians and patients. Misoprostol, high-dose H2-receptor antagonists, proton-pump inhibitors, and COX-2 inhibitors have been shown to reduce this risk. Misoprostol and proton-pump inhibitors are more effective than H2-receptor antagonists; dose-related diarrhea limits the clinical utility of misoprostol. These strategies may not provide enough protection in patients taking concomitant low-dose aspirin therapy or patients with a history of ulcer complications.

CONCLUSIONS:

COX-2 inhibitors and proton-pump inhibitors are effective and well-tolerated therapies to reduce clinically significant upper gastrointestinal adverse events associated with NSAIDs.

Management of peptic ulcer disease not related to Helicobacter

Most peptic ulcers not due to Helicobacter pylori are caused by non-steroidal anti-inflammatory drugs (NSAID), among which an important subset are due to vascular protective ("low-dose") aspirin therapy. Non-steroidal anti-inflammatory drugs ulcers heal quite quickly when treated with a proton pump inhibitor (PPI), even though the NSAID is continued. If the NSAID can be stopped, the ulcers heal readily with either a PPI or a histamine H2-receptor antagonist (H2-RA). If anti-inflammatory treatment is still needed after ulcers are healed, prophylactic co-therapy with a PPI or misoprostol will reduce the risk of ulcer recurrence by about 60-80%. The alternative of switching to a highly selective cyclooxygenase-2 inhibitor has been shown to reduce the risk of a complicated ulcer by about 50-60%, unless low-dose aspirin treatment needs to be given as well for vascular disease. Idiopathic ulcers are becoming more frequent as H. pylori prevalence falls. Some may be sequelae of previous NSAID ulceration even though the NSAID has been ceased and the original ulcer had healed. These are best treated with an H2-RA or a PPI, followed by long-term maintenance with either of these (often in half the healing dosage) to prevent recurrence. Ulcers due to Zollinger-Ellison syndrome and other hypergastrinemia syndromes are rare, and largely beyond the scope of this review.

Understanding NSAIDs: from aspirin to COX-2

Nonsteroidal anti-inflammatory drugs (NSAIDs) annually account for 70 million prescriptions and 30 billion over-the-counter (OTC) medications sold in the United States alone. Despite our familiarity with these drugs, NSAIDs are full of paradoxes that pose significant challenges for the medical community. Although NSAIDs are among the oldest of drugs, new formulations continue to come to market. Some formulas are safe enough to be sold OTC for use in infants with fever, while others are available only as a prescription medication and are a leading cause of iatrogenic reactions, hospitalizations, and death. Physicians face the choice of prescribing lower cost, older NSAIDs versus the more expensive but potentially safer ones. The use of NSAIDs is clearly increasing. Factors contributing to this increase are the availability of OTC preparations and the aging of the population with a concomitant increase in osteoarthritis. One indication of the popularity of NSAIDs is that following the introduction of 2 new cyclooxygenase-2 (COX-2) selective inhibitors in 1999, these drugs immediately became the most frequently prescribed new drugs in the United States. This article will familiarize the practitioner with the various types of NSAIDs, including the newer COX-2 formulations, their mechanism of action, and potential adverse reactions and efficacy. Although most practitioners are aware of the indications for NSAIDs, research is continuing to explore nontraditional applications. A new framework is being created that will allow new additions to the NSAID class of medications.