To optimize the use of anti-inflammatory drug treatment, clear guidelines are needed to identify patients at increased risk of adverse upper gastrointestinal events. Evidence from numerous studies indicates that several factors can be used to stratify patients according to risk (Table 2). Best quality drugs are waiting – buy levaquin online to spend less time and money.
Stratification of risk for upper gastrointestinal events
|Time elapsed since diagnosis|
|Multiple high dose NSAIDs and/or|
NSAIDs Nonsteroidal anti-inflammatory drugs
Based on a critical review of the current clinical evidence and the opinion of the expert panel, recommendations can be made for the optimal use of conventional NSAIDs and coxibs according to individual patient risk profiles (Table 3).
Treatment recommendations for patients requiring anti-inflammatory therapy
|Patient profile||Treatment recommendations|
|De novo patient|
|High-risk patient||Coxib plus GPA|
|Previous upper gastrointestinal bleeding; age 75 years or older; concomitant|
|treatment with steroids or anticoagulants; or two or more other risk factors (Table 1)|
|Intermediate-risk patient||Coxib alone|
|One risk factor plus no upper gastrointestinal bleeding plus aged 60 to 75 years|
|Low-risk patient||NSAID or coxib alone|
|No risk factors||Discuss features of both drugs with patient|
|Previously treated patient|
|Previous ulcer disease (Helicobacterpylori‘-positive or -negative)||Coxib, eradication of H pylori if present|
|Prior complicated ulcer at any site||Coxib plus GPA|
|Eradication of H pylori if present|
|Mild or intermittent||H2RA or PPI|
|Moderate or nonresponding||PPI|
|Current therapy with NSAID plus GPA||Re-evaluate as for de novo patients|
|Risk factors: treat as for de novo patients|
GPA Gastroprotective agent; H2RA H2-receptor antagonist; NSAID Nonsteroidal anti-inflammatory drug; PPI Proton pump inhibitor
When considering a GPA, more predictable and prolonged acid suppression with a PPI is effective for ulcer healing and prevention, while misoprostol is effective for the prevention of gastric ulcer but is not widely prescribed because of side effects.
Patients can be stratified by risk. For de novo patients with none of the specified risk factors for gastrointestinal injury, both conventional NSAIDs and coxibs given alone can be considered, following a discussion with the patient about the relative effectiveness, adverse effects and cost. For high-risk patients with a history of previous upper gastrointestinal bleeding, aged 75 years or older, on cotherapy with corticosteroids or anticoagulants, or having at least two other risk factors (see Table 1), it is wise to combine a coxib with a GPA. In the remaining patients at intermediate risk, defined as the presence of one risk factor in patients younger than 75 years of age but older than 60 years of age and no history of bleeding, a coxib is recommended as the treatment of choice.