What are the guidelines for using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in patients with a history of gastritis?

From the Guidelines

Patients with a history of gastritis should use NSAIDs cautiously and only when necessary, preferably at the lowest effective dose for the shortest duration possible, and consider co-prescription of a gastroprotective agent, such as a proton pump inhibitor (PPI), to minimize the risk of gastrointestinal complications. For those requiring NSAIDs despite gastritis history, a PPI like omeprazole (20-40mg daily), pantoprazole (40mg daily), or esomeprazole (20-40mg daily) may be used to reduce the risk of gastrointestinal toxicity 1. Alternatively, COX-2 selective NSAIDs like celecoxib (100-200mg daily) may be used as they pose less gastrointestinal risk than traditional NSAIDs such as ibuprofen, naproxen, or diclofenac 1.

Key considerations for NSAID use in patients with a history of gastritis include:

• Assessing the patient's individual risk factors for gastrointestinal complications, such as age, history of peptic ulcer disease, and use of concomitant medications like aspirin or anticoagulants 1
• Selecting the lowest effective dose and shortest duration of NSAID therapy necessary to achieve the desired therapeutic effect 1
• Co-prescribing a gastroprotective agent, such as a PPI, to reduce the risk of gastrointestinal complications in high-risk patients 1
• Monitoring patients regularly for symptoms of gastrointestinal toxicity, such as abdominal pain, nausea, vomiting, or black stools 1

It is essential to weigh the benefits and risks of NSAID therapy in patients with a history of gastritis and to consider alternative treatment options when possible. By taking a cautious and individualized approach to NSAID use, healthcare providers can help minimize the risk of gastrointestinal complications and optimize patient outcomes.

From the FDA Drug Label

Misoprostol tablets are indicated for reducing the risk of NSAID (nonsteroidal anti-inflammatory drugs, including aspirin)–induced gastric ulcers in patients at high risk of complications from gastric ulcer, e.g., the elderly and patients with concomitant debilitating disease, as well as patients at high risk of developing gastric ulceration, such as patients with a history of ulcer. Lansoprazole delayed-release capsules are indicated in adults for reducing the risk of NSAID-associated gastric ulcers in patients with a history of a documented gastric ulcer who require the use of an NSAID.

Guidelines for using NSAIDs in patients with a history of gastritis:

• Risk Reduction: Consider using medications like misoprostol or lansoprazole to reduce the risk of NSAID-associated gastric ulcers in patients with a history of gastritis 2.
• Patient Selection: Identify patients at high risk of complications from gastric ulcer, such as the elderly and those with concomitant debilitating disease, and consider alternative treatments or prophylactic measures 2.
• Duration of Therapy: Misoprostol should be taken for the duration of NSAID therapy to reduce the risk of gastric ulcers 2.
• Monitoring: Closely monitor patients with a history of gastritis for signs of gastric ulceration or other adverse effects when using NSAIDs.
• Alternative Treatments: Consider using alternative treatments, such as acetaminophen, for patients with a history of gastritis who require pain management 3.

From the Research

Guidelines for Using NSAIDs in Patients with a History of Gastritis

• The use of NSAIDs in patients with a history of gastritis requires careful consideration of the potential risks and benefits 4, 5, 6, 7.
• Patients with a history of gastritis are at increased risk of developing NSAID-induced gastroduodenal lesions, including ulcers and bleeding 6, 7.
• The risk of NSAID-induced gastrointestinal complications can be reduced by using the lowest possible dosage of NSAID, avoiding concomitant use of NSAIDs and corticosteroids, and using preventive therapy such as proton pump inhibitors or misoprostol 5, 6, 7.
• Proton pump inhibitors have been shown to be effective in healing NSAID-induced ulcers and reducing the risk of gastrointestinal complications 5, 6.
• Misoprostol is also effective in preventing NSAID-induced gastroduodenal lesions, but may be associated with side effects such as diarrhea and abdominal pain 5, 6.
• Histamine H2 receptor antagonists may be useful in preventing NSAID-induced duodenal ulcers, but are less effective in preventing gastric ulcers 5, 6.
• The decision to employ a protective strategy to decrease NSAID-associated GI clinical events should be based on risk stratification, taking into account factors such as age, prior history of upper GI events, and use of concomitant medications 7.

Prevention and Treatment of NSAID-Induced Gastropathy

• Primary prevention of NSAID-related gastropathy can be enhanced by better education for clinicians and patients, and by using gastroprotective agents such as proton pump inhibitors or misoprostol 4.
• Treatment of NSAID-induced ulcers should involve reduction or discontinuation of the NSAID, and use of a proton pump inhibitor or other effective therapy 5, 6.
• Alternative therapies, such as food-based products, may also be considered, although the evidence for their effectiveness is limited and more rigorous clinical studies are needed 8.