What medications are contraindicated in patients with gastritis?

Medications Contraindicated in Gastritis

NSAIDs and aspirin are strongly contraindicated in patients with gastritis due to their high risk of causing gastric mucosal damage, ulceration, bleeding, and potentially life-threatening complications. 1, 2, 3

Contraindicated Medications in Gastritis

Primary Contraindications:

1. Non-steroidal Anti-inflammatory Drugs (NSAIDs)

   • All traditional NSAIDs increase risk of gastric mucosal damage through COX-1 inhibition 1
   • Highest risk NSAIDs:
     • Piroxicam (long half-life, significant GI risk) 4
     • Ketorolac 1
     • Indomethacin 1
     • Sulindac 1
   • Even short-term use can cause erosive gastritis and GI bleeding 2

2. Aspirin (all forms)

   • Even low-dose aspirin (81-325 mg/day) increases gastritis risk 2-4 times 1
   • Enteric-coated formulations do not significantly reduce gastritis risk 1
   • Particularly dangerous in elderly patients (>60 years) 3

3. COX-2 Selective Inhibitors (Coxibs)

   • While developed to minimize GI toxicity, still contraindicated in active gastritis 1
   • Celecoxib carries black box warning for GI events 1

Relative Contraindications (Use with Caution):

1. Corticosteroids

   • Significantly increase risk when combined with NSAIDs 1, 4
   • Independent risk factor for gastric mucosal damage 1

2. Anticoagulants/Antithrombotics

   • Warfarin, direct oral anticoagulants, and other antithrombotics increase bleeding risk 1, 4
   • Particularly dangerous when combined with NSAIDs or aspirin 1

Risk Stratification and Management

Very High Risk (Absolute Contraindication)

• Recent or active gastritis with ulceration
• History of GI bleeding
• Multiple risk factors (age >65, H. pylori infection, concurrent anticoagulants)
• Recommendation: Complete avoidance of all NSAIDs and aspirin 1

High Risk

• History of gastritis without recent complications
• Age >65 with additional risk factors
• Recommendation: Avoid NSAIDs/aspirin if possible; if absolutely necessary, use COX-2 inhibitor with PPI co-therapy 4

Moderate Risk

• Mild gastritis or history of gastritis that has resolved
• Age >60 with no additional risk factors
• Recommendation: Use alternative analgesics (acetaminophen); if NSAID needed, use lowest effective dose with PPI co-therapy 4

Gastroprotective Strategies (If NSAIDs Cannot Be Avoided)

1. Proton Pump Inhibitors (PPIs)

   • First-line gastroprotection if NSAID use is unavoidable 1
   • Standard dose (e.g., omeprazole 20mg daily) is sufficient 4
   • Must be continued for entire duration of NSAID treatment 4

2. Misoprostol

   • Alternative to PPIs (200 μg three times daily) 1
   • Side effects (diarrhea, abdominal pain) may limit adherence 4

3. H. pylori Testing and Treatment

   • Eradication of H. pylori recommended before starting NSAIDs in patients with history of gastritis 1
   • Reduces risk of NSAID-induced complications 1

Important Clinical Considerations

• NSAIDs cause gastric damage through both topical effects and systemic prostaglandin inhibition 1
• Elderly patients (>60 years) have 3-5 times higher risk of NSAID-related gastric complications 1
• The mortality rate among patients hospitalized for NSAID-induced upper-GI bleeding is 5-10% 1
• Rebound acid hypersecretion may occur when PPIs are discontinued, potentially worsening gastritis symptoms 1
• Using the lowest effective dose for the shortest duration is essential if NSAIDs must be used 4

Alternative Pain Management Options

• Acetaminophen (first-line alternative for pain)
• Topical NSAIDs (for localized musculoskeletal pain)
• Non-pharmacological approaches (physical therapy, heat/cold therapy)
• Tramadol or other non-NSAID analgesics if appropriate

Remember that even short-term use of NSAIDs or aspirin can trigger or worsen gastritis, and the risk persists throughout the duration of treatment. The safest approach is complete avoidance of these medications in patients with active gastritis.