Does alcohol consumption increase the risk of gastrointestinal complications with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

From the Guidelines

Alcohol consumption significantly increases the risk of gastrointestinal complications when taking NSAIDs, and it is recommended to avoid alcohol when taking these medications, especially for patients with a history of peptic ulcer disease or significant alcohol use. Combining alcohol with medications like ibuprofen, naproxen, aspirin, or celecoxib raises the chance of developing stomach irritation, ulcers, and bleeding, as both substances independently irritate the stomach lining and reduce its protective mechanisms 1. According to the study published in the Journal of the National Comprehensive Cancer Network, patients at high risk for GI toxicities include those with a history of peptic ulcer disease or significant alcohol use, which is defined as 2 alcoholic beverages per day 1.

The interaction between alcohol and NSAIDs occurs because both substances enhance the ability to inhibit prostaglandins that normally protect the stomach lining, while also increasing stomach acid production and slowing healing. For safety, it's best to avoid alcohol when taking NSAIDs, especially if using them regularly or at higher doses. If you must take NSAIDs regularly, consider using the lowest effective dose, taking them with food, and discussing with your healthcare provider about possibly adding a proton pump inhibitor like omeprazole for stomach protection, as recommended by the consensus development conference on the use of nonsteroidal anti-inflammatory agents 1.

Some key points to consider when taking NSAIDs and alcohol include:

• Limiting the duration and dosage of NSAIDs
• Avoiding combination NSAID therapy
• Treating known H pylori infection
• Monitoring patients taking both nsNSAIDs and coxibs for cardiovascular side effects
• Assessing for and treating H pylori if present, and instituting gastroprotection with misoprostol or PPIs in high-risk patients 1.

Overall, the risk of gastrointestinal complications with NSAIDs can be minimized by avoiding alcohol, using the lowest effective dose, and taking precautions to protect the stomach lining.

From the FDA Drug Label

Other factors that increase the risk of GI bleeding in patients treated with NSAIDs include ... use of alcohol, older age, and poor general health status Patients with a prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed compared to patients treated with neither of these risk factors Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore, special care should be taken in treating this population.

Yes, alcohol consumption increases the risk of gastrointestinal complications with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) 2, 3.

• Key factors that increase the risk of GI bleeding in patients treated with NSAIDs include use of alcohol.
• High-risk patients should be treated with caution and alternate therapies that do not involve NSAIDs should be considered.

From the Research

Risk of Gastrointestinal Complications with NSAIDs and Alcohol Consumption

• The use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can increase the risk of gastrointestinal (GI) complications, and alcohol consumption may further exacerbate this risk 4, 5, 6.
• Studies have shown that factors such as older age, history of peptic ulcer disease, concomitant corticosteroid use, cigarette smoking, and high dose or multiple NSAID therapy can increase the risk of GI damage and complications in chronic NSAID users 4.
• Alcohol consumption has been identified as a risk factor for GI complications in NSAID users, with heavy alcohol intake independently increasing the risk of acute major upper GI bleeding 5, 6.
• The risk of GI bleeding or ulceration may be higher in alcoholic patients taking NSAIDs, and the optimal strategy in prescribing pain relievers to those who consume alcohol is to use one drug at a time and to clearly communicate its generic name 7.

Interaction between Alcohol and NSAIDs

• The presence of both NSAID use and a history of alcohol abuse can lead to a higher risk of severe GI events, with an odds ratio of 10.2* compared to an additive risk of 5.8* 5.
• The use of over-the-counter (OTC) NSAIDs, such as aspirin and ibuprofen, can increase the risk of GI bleeding, and alcohol consumption may further increase this risk 5, 6.
• The risk of acute major upper GI bleeding is similarly associated with the use of aspirin and ibuprofen at all levels of alcohol consumption, with heavy alcohol intake independently increasing the risk 6.

Prevention and Treatment

• Patients taking NSAIDs who are at high risk for GI complications should receive therapy to decrease their risk for ulceration, and the use of one drug at a time with clear communication of its generic name is recommended 7.
• Acetaminophen is considered the safest OTC analgesic for patients who consume alcohol, and OTC NSAID users should be carefully advised as to recommended dose and dosing limits 7.