Is there a benefit to using proton pump inhibitors (PPIs) for gastrointestinal protection in patients treated with high doses of nonsteroidal anti-inflammatory drugs (NSAIDs) for myopericarditis?

PPI Use for GI Protection in Patients on High-Dose NSAIDs for Myopericarditis

Proton pump inhibitors (PPIs) should be used for gastrointestinal protection in patients receiving high-dose NSAIDs for myopericarditis, particularly in those with additional risk factors for GI bleeding. 1

Rationale for PPI Co-therapy with NSAIDs

High-dose NSAIDs used for myopericarditis significantly increase the risk of gastrointestinal complications through:

1. Direct topical mucosal injury
2. Systemic inhibition of prostaglandin synthesis via COX inhibition

PPIs provide superior protection compared to other options:

• PPIs can reduce the rate of endoscopic NSAID-related ulcers by approximately 90% 1
• PPIs are more effective than H2-receptor antagonists, which only decrease the risk of duodenal ulcers but not gastric ulcers 1
• While misoprostol has proven efficacy in reducing NSAID-associated GI complications by 40%, its use is limited by adverse effects (abdominal pain, diarrhea, nausea) in approximately 20% of patients 1

Risk Assessment for PPI Co-therapy

The decision to use PPI co-therapy should be based on the following risk factors:

High-Risk Patients (Definitely Need PPI Co-therapy):

• Age >60 years 1
• History of peptic ulcer disease or GI bleeding 1
• Concurrent use of multiple NSAIDs or aspirin 1
• Concurrent use of anticoagulants or corticosteroids 1
• Severe medical comorbidities 1

Additional Considerations:

• Higher doses of NSAIDs (as used in myopericarditis) increase risk 1
• Longer duration of NSAID therapy increases risk 1
• H. pylori infection increases risk and should be tested for and eradicated in high-risk patients 1

Effectiveness of PPI Protection

The evidence strongly supports PPI co-therapy with NSAIDs:

• PPIs significantly reduce the risk of both gastric and duodenal ulcers in NSAID users 1
• In high-risk patients with previous ulcer bleeding, omeprazole was more effective than H. pylori eradication alone in preventing recurrent bleeding (4.4% vs 18.8%) 1
• PPIs have been widely adopted in clinical practice despite the lack of large outcome trials 1

Implementation Considerations

When prescribing PPIs for patients on high-dose NSAIDs for myopericarditis:

1. Standard once-daily dosing is typically sufficient for gastroprotection 1
2. Begin PPI therapy concurrently with NSAID initiation rather than waiting for symptoms to develop
3. Continue PPI for the entire duration of high-dose NSAID therapy
4. Consider H. pylori testing in patients with history of peptic ulcer disease 1

Potential Limitations and Concerns

While providing significant protection, clinicians should be aware of:

• PPIs may be associated with increased rates of pneumonia with long-term use 1
• Patient compliance is essential for effectiveness 1
• PPIs primarily protect the upper GI tract; mechanisms for lower GI tract protection are limited 1
• Some patients may develop rebound acid hypersecretion upon PPI discontinuation 1

Conclusion for Clinical Practice

For patients receiving high-dose NSAIDs for myopericarditis, PPI co-therapy represents the most effective and well-tolerated strategy for reducing the risk of serious GI complications. The benefit of preventing potentially life-threatening GI bleeding clearly outweighs the potential risks of PPI therapy, especially during the typically limited duration of high-dose NSAID treatment for myopericarditis.