What medications are contraindicated in patients with gastritis?

Medications Contraindicated in Gastritis

Nonsteroidal anti-inflammatory drugs (NSAIDs) are strongly contraindicated in patients with gastritis due to their high risk of causing gastric mucosal damage, ulceration, bleeding, and perforation. 1, 2

Contraindicated Medications in Gastritis

Primary Contraindications:

1. NSAIDs (All Classes):

   • Nonselective NSAIDs (inhibit both COX-1 and COX-2)
     • Aspirin (even low-dose)
     • Ibuprofen
     • Naproxen
     • Indomethacin
     • Diclofenac
     • Ketoprofen
   • COX-2 selective inhibitors (less gastrotoxic but still contraindicated)
     • Celecoxib

2. Medications with High Gastric Irritation Potential:

   • Piroxicam (particularly contraindicated due to long half-life and high GI risk) 2
   • Ketorolac (associated with higher GI toxicity) 1

Mechanism of Gastric Damage

NSAIDs cause gastric damage through multiple mechanisms:

1. Prostaglandin Inhibition: NSAIDs inhibit COX-1 enzyme, reducing production of gastroprotective prostaglandins (PGE2 and prostacyclin) 1
2. Direct Topical Irritation: Particularly with acidic NSAIDs 3
3. Impaired Mucosal Defense: Reduced mucus and bicarbonate secretion
4. Microvascular Injury: Leading to reduced mucosal blood flow

Risk Factors for NSAID-Induced Gastric Complications

The risk of serious gastrointestinal complications is significantly higher in patients with:

• History of previous peptic ulcer or ulcer complications (highest risk factor) 1, 2
• Advanced age (>65 years) - risk increases approximately 4% per year of age 1
• Concomitant use of:
  • Multiple NSAIDs (including OTC products)
  • Low-dose aspirin
  • Corticosteroids
  • Anticoagulants
• High-dose NSAID therapy 1, 2
• Helicobacter pylori infection 1

Alternative Medications for Patients with Gastritis

When analgesic/anti-inflammatory treatment is necessary in patients with gastritis:

1. First-line alternatives:

   • Acetaminophen/paracetamol (safest option for pain relief) 2
   • Topical NSAIDs (for localized musculoskeletal pain) 2

2. If NSAIDs are absolutely necessary:

   • Use the lowest effective dose for the shortest duration 2
   • Add gastroprotective therapy:
     • Proton pump inhibitors (PPIs) - standard dose (e.g., omeprazole 20mg daily) 1, 2
     • Misoprostol (200μg three times daily) - effective but has side effects like diarrhea 2
     • H. pylori eradication if positive (reduces risk of ulcers) 1

3. NSAIDs with lower GI risk profile (if absolutely necessary):

   • Ibuprofen at lowest effective dose (≤1200mg/day) 2, 4
   • COX-2 selective inhibitors (celecoxib) - still risky but less than traditional NSAIDs 1

Monitoring and Prevention

If NSAIDs must be used in patients with gastritis:

1. Mandatory gastroprotection with PPI therapy for the entire duration of NSAID treatment 2
2. Regular monitoring for GI symptoms, signs of bleeding, and anemia 2
3. Immediate discontinuation if symptoms of GI bleeding occur (black stools, hematemesis) 5
4. Avoid alcohol consumption during NSAID therapy 5

Special Considerations

• Elderly patients (>65 years) have 2-3.5 times higher risk of NSAID complications and require special caution 2
• Low-dose aspirin for cardiovascular protection still increases GI bleeding risk 2-4 fold and should be used with PPI protection in gastritis patients 1
• Enteric-coated aspirin does not significantly reduce the risk of upper GI bleeding compared to regular aspirin 1

Remember that even short-term use of NSAIDs can exacerbate gastritis and lead to serious complications. The safest approach is complete avoidance of all NSAIDs in patients with active gastritis until healing is complete.