Can I prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to a patient with a history of gastric bypass surgery for a rheumatoid arthritis flare?

From the Guidelines

Prescribing NSAIDs to patients with a history of gastric bypass surgery requires caution but is not absolutely contraindicated, and for a rheumatoid arthritis flare, consider using a selective COX-2 inhibitor like celecoxib (Celebrex) at a lower starting dose (100mg twice daily) rather than traditional NSAIDs, as it may have a lower risk of gastrointestinal complications, as suggested by 1. When managing a patient with a history of gastric bypass surgery who is experiencing a rheumatoid arthritis flare, it is crucial to weigh the benefits and risks of NSAID use carefully. The patient's altered gastrointestinal anatomy increases their risk of developing ulcers, bleeding, and perforation with NSAID use, as noted in 1. Some key points to consider include:

• The use of NSAIDs can lead to serious gastrointestinal complications, including bleeding, perforation, and obstruction, with an average relative risk 3- to 5-fold greater among NSAID users than among nonusers, as reported in 1.
• Selective COX-2 inhibitors like celecoxib may have a lower risk of gastrointestinal complications compared to traditional NSAIDs, but they are not without risk, and their use should be carefully considered, especially in patients with a history of gastric bypass surgery, as discussed in 1 and 1.
• The concomitant use of a proton pump inhibitor (PPI) such as omeprazole 20mg daily can provide gastroprotection and reduce the risk of gastrointestinal complications, as suggested by 1 and 1.
• Alternative approaches, such as acetaminophen (up to 3000mg daily in divided doses), local corticosteroid injections, or consultation with rheumatology for disease-modifying antirheumatic drugs, should be considered for longer-term pain management, as these options may have a more favorable risk-benefit profile for patients with a history of gastric bypass surgery, as noted in 1 and 1. It is essential to monitor the patient closely for signs of gastrointestinal complications, such as abdominal pain, black stools, or vomiting, which could indicate the need for immediate medical attention, as emphasized in 1 and 1. Ultimately, the decision to prescribe NSAIDs to a patient with a history of gastric bypass surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors, medical history, and current health status, as well as the potential benefits and risks of NSAID use, as discussed in 1, 1, 1, and 1.

From the FDA Drug Label

NSAIDs can cause serious side effects, including: • Increased risk of bleeding, ulcers, and tears (perforation) of the esophagus (tube leading from the mouth to the stomach), stomach and intestines: o anytime during use o without warning symptoms o that may cause death • The risk of getting an ulcer or bleeding increases with: o past history of stomach ulcers, or stomach or intestinal bleeding with use of NSAIDs o taking medicines called “corticosteroids”, “antiplatelet drugs”, “anticoagulants”, “SSRIs” or “SNRIs” o increasing doses of NSAIDs o older age o longer use of NSAIDs o poor health o smoking o advanced liver disease o drinking alcohol o bleeding problems

The patient has a history of gastric bypass surgery, which may increase the risk of gastrointestinal complications. NSAIDs should be used with caution in this patient. The risk of bleeding, ulcers, and perforation is increased with NSAID use, especially in patients with a history of stomach ulcers or intestinal bleeding.

• Key considerations:
  • Past history of stomach ulcers or intestinal bleeding
  • Increased risk of gastrointestinal complications with NSAID use
  • Need for close monitoring and caution when prescribing NSAIDs Given the potential risks, it is recommended to avoid prescribing NSAIDs for this patient or to use the lowest effective dose for the shortest duration necessary and monitor the patient closely for signs of gastrointestinal complications 2.

From the Research

NSAID Use in Patients with a History of Gastric Bypass Surgery

• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with a history of gastric bypass surgery is a concern due to the increased risk of peptic ulcers and other complications 3, 4, 5.
• A study published in 2016 found that informing patients and their general practitioners about the risks of NSAID use after bariatric surgery did not significantly reduce the use of NSAIDs 3.
• Another study published in 2022 found that continuous NSAID use of ≥30 days was a significant risk factor for the development of peptic ulcers after Roux-en-Y gastric bypass (RYGB), whereas temporary use (<30 days) was not 4.
• A 2011 study found that ulcers at the gastrojejunostomy site were more common in patients who had undergone B-II gastric bypass compared to those who had undergone Roux-en-Y gastric bypass, and that the use of NSAIDs was a significant risk factor for the development of these ulcers 5.

Alternative Options for Pain Management

• Selective cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib and etodolac, may be safer alternatives to non-selective NSAIDs for patients with a history of gastric bypass surgery 6.
• A 2023 study found that etodolac and celecoxib maintained unaffected absorption after bariatric surgery, whereas etoricoxib had impaired absorption 6.

Comparative Safety of Bariatric Surgical Procedures

• A 2021 study compared the safety of sleeve gastrectomy and gastric bypass up to 5 years after surgery and found that sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions, but a higher long-term risk of surgical revision 7.
• The study also found that patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality, complications, and reintervention compared to those undergoing gastric bypass 7.