Non-steroidal anti-inflammatory drugs (NSAIDS) are useful for the relief of acute and chronic pain. Patients with both osteoarthritis and rheumatoid arthritis are often treated with these medicines. A significant problem associated with these drugs is the effects on the stomach and bowel.
In particular, adverse effects are noted on the lining of the gut- the gastrointestinal mucosa.
This side effects can present in a number of ways including: esophagitis (inflammation of the esophagus); esophageal stricture (narrowing of the esophagus); gastritis (inflammation of the stomach lining); mucosal erosions (holes in the protective lining of the bowel wall); bleeding; as well as the development of ulcer in the stomach or duodenum (beginning of the small intestine) or its complications including perforation, bowel obstruction, and death.
The small and large bowel mucosa can be affected leading to narrowing of the bowel. This is called a stricture and can lead to bowel obstruction and perforation. There is also evidence that NSAIDS can affect the permeability of the gut, possibly allowing the development of antigen antibody reactions to occur. This is the basis for the theories regarding food allergies.
Although patients may develop important NSAID-caused GI damage with no warning, the following are known risk factors for the development of GI toxicity associated with NSAIDs:
• Age greater than 65 years
• History of peptic ulcer disease or bleeding from the GI tract
• Use of anti-ulcer therapy for any reason
• Simultaneous use of glucocorticoids (steroid drugs like prednisone), particularly in patients with rheumatoid arthritis
• Other medical diseases such as cardiovascular disease
• Patients with severe rheumatoid arthritis
• Large doses of NSAID
• Combinations of NSAIDs
The COX-2 selective drugs were developed to reduce the incidence of these potentially lethal side-effects.
While most of the media attention has been focused on COX-2 drugs and cardiovascular side effects, a little known fact is that all NSAIDS- regular NSAIDS as well as COX-2 NSAIDS- have the same risk when it comes to heart attack and stroke. This problem extends to the common over the counter NSAIDS such as ibuprofen and naproxyn.
The cardiovascular data will be reviewed in another article.
By: Nathan Wei, MD, FACP, FACR