Gastrointestinal Risk

NSAIDs harm the gastrointestinal mucosa in two ways: by direct irritation and by inhibition of the production of protective prostaglandins via COX-1 inhibition. In the general population, patients who use NSAIDs have about a 4-fold increased risk of GI bleed or perforation. In the hospice population, most patients are already at increased risk of NSAID-induced GI toxicity because of their age (age > 60 is a significant risk factor). Additional risk factors include history of peptic ulcer disease and concomitant use of antiplatelets (e.g., aspirin or clopidogrel), anticoagulants (e.g., warfarin), or corticosteroids. In these patients, which NSAIDs confer the lowest degree of gastrointestinal risk?

A number of studies have compared gastrointestinal risk among NSAIDs. The results of a few of these studies are summarized below, with the NSAIDs listed according to GI risk, from highest to lowest (followed by relative risk, if provided):

In summary, evidence suggests that ibuprofen and the agents with relatively more COX-2 selectivity (celecoxib, meloxicam, nabumetone) have the lowest gastrointestinal risk, and piroxicam and ketorolac have the highest risk.

However, note that even those NSAIDs that are considered “lower risk” are not necessarily benign. In patients at high GI risk who must use an NSAID for pain relief, add a gastroprotective agent, such as a proton pump inhibitor or misoprostol.

What do you do when a patient has both cardiovascular and gastrointestinal risk factors? And what about patients with renal impairment? Watch the blog for How to Choose an NSAID for Hospice Patients, Part 3.

We look forward to your Comments and Questions Below.

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