Intermediate- and low-risk patients with previous ulcer disease should be considered for treatment with a coxib, irrespective of H pylori status, with eradication therapy being prescribed when appropriate and in keeping with current Canadian guidelines. In patients with previous complicated ulcer disease (ie, bleeding or perforation), the addition of a GPA should be considered. Patients who require an NSAID for the first time and who have a history of an H pylori-positive duodenal ulcer disease with confirmed H pylori eradication, can probably be considered to have returned to a baseline risk of gastrointestinal injury.
Although GPA coprescription is frequently driven by the presence of abdominal pain and dyspeptic symptoms, these are not predictive of endoscopic findings or the potential for a serious outcome in patients receiving NSAIDs. In the absence of other risk factors, dyspepsia in NSAID users can be managed initially with an H2RA, although it is important to emphasize that there is no evidence that this strategy protects against other serious gastrointestinal events. There are no primary studies of symptomatic relief with the use of PPIs in patients with NSAID-associated dyspepsia, but due to their superior anti-secretory effect, PPIs are likely to be more effective than H2RAs in this situation. Moreover, PPIs may provide the additional benefit of a reduction in ulcer incidence and gastrointestinal complications. Outcome studies have reported a similar and significant reduction in dyspepsia with the use of coxibs that was maintained across the duration of the studies; however, some dyspeptic symptoms were still present.
Patients who are already receiving established therapy with an NSAID plus a GPA should be reviewed according to these recommendations. Patients moving from the high-risk to the intermediate-risk group by virtue of a change in their risk factors, such as cotherapy (multiple NSAIDs, corticosteroids or anticoagulant therapy), should be reassessed with a view to stopping the GPA when appropriate or switching to a coxib alone. Most advantageous shopping – buy mircette for everyone to spend less.
The use of multiple NSAIDs carries a high risk of adverse upper gastrointestinal events, and physicians who prescribe conventional NSAIDs or coxibs should warn their patients against taking concomitant over-the-counter NSAIDs. The use of conventional NSAIDs, even at over-the-counter doses, in combination with a coxib, reduces the benefits of the coxib and increases the patient’s risk of having an adverse gastrointestinal event.