Which Nonsteroidal Anti-Inflammatory Drug (NSAID) can be used with gastroparesis?

From the Guidelines

Celecoxib is the preferred NSAID for patients with gastroparesis due to its selective COX-2 inhibition, which causes less gastric irritation and has a lower risk of exacerbating gastroparesis symptoms. Unlike traditional NSAIDs such as ibuprofen, naproxen, or diclofenac, celecoxib does not significantly delay gastric emptying, which is already compromised in gastroparesis patients 1. The typical dosage is 100-200 mg once or twice daily, depending on the condition being treated. When prescribing celecoxib for patients with gastroparesis, it should be taken with food to minimize any potential gastric discomfort, though this is less necessary than with traditional NSAIDs.

Traditional NSAIDs inhibit both COX-1 and COX-2 enzymes, with COX-1 inhibition leading to reduced protective gastric mucus and increased acid secretion, potentially worsening gastroparesis symptoms. In contrast, celecoxib's selective COX-2 inhibition reduces the risk of gastrointestinal complications, making it a safer option for patients with gastroparesis 1. If celecoxib cannot be used, topical NSAIDs may be considered as they have minimal systemic absorption and gastric effects. However, the use of celecoxib is generally preferred due to its favorable gastrointestinal safety profile.

Key considerations when prescribing NSAIDs to patients with gastroparesis include:

• Selecting a COX-2 inhibitor like celecoxib to minimize gastric irritation
• Avoiding traditional NSAIDs that inhibit both COX-1 and COX-2 enzymes
• Taking the medication with food to reduce potential gastric discomfort
• Monitoring for gastrointestinal complications and adjusting the treatment plan as needed
• Considering alternative options like topical NSAIDs if celecoxib is not suitable.

From the FDA Drug Label

Misoprostol produces a moderate decrease in pepsin concentration during basal conditions, but not during histamine stimulation It has no significant effect on fasting or postprandial gastrin nor on intrinsic factor output Cytotec is intended for administration along with nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, to decrease the chance of developing an NSAID-induced gastric ulcer.

The NSAID that can be used with gastroparesis is not explicitly stated in the provided drug labels. However, based on the information provided, ibuprofen, naproxen, aspirin, tolmetin, and piroxicam are mentioned as NSAIDs that can be used with misoprostol to reduce the risk of gastric ulcers.

• Ibuprofen
• Naproxen
• Aspirin
• Tolmetin
• Piroxicam 2, 2, 2

From the Research

NSIAD Options for Gastroparesis

There are no direct references to the use of NSIADs with gastroparesis in the provided studies. However, the following information can be gathered regarding the use of NSIADs and their potential gastrointestinal side effects:

• The use of selective cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib, is considered safer for the gastrointestinal tract than traditional NSIADs 3.
• Patients with gastrointestinal risk factors may benefit from cotherapy with a proton pump inhibitor (PPI) or misoprostol, or a COX-2 inhibitor alone 3.
• The combination of a COX-2 inhibitor and a PPI is considered the best option for patients with moderate to high gastrointestinal risk and low cardiovascular risk 4.
• Some studies suggest that the use of a non-selective NSIAD with a PPI may be as effective as the use of a COX-2 selective inhibitor in preventing the recurrence of ulcer complications 5.

Potential NSIAD Options

Based on the provided studies, the following NSIADs may be considered:

• Celecoxib: a selective COX-2 inhibitor with a lower gastrointestinal risk 3, 4.
• Ketoprofen: a non-selective NSIAD that can be used in combination with a PPI, such as omeprazole, to reduce gastrointestinal risk 6.
• Naproxen: a non-selective NSIAD that may be considered for patients with high cardiovascular risk and low to moderate gastrointestinal risk 4.

Gastroprotective Strategies

The use of gastroprotective strategies, such as PPIs, is recommended for patients at risk of NSIAD-induced gastrointestinal complications:

• Omeprazole is effective in preventing gastroduodenal ulcers, maintaining remission, and alleviating dyspeptic symptoms in NSIAD recipients 7, 6.
• The fixed-dose combination of ketoprofen and omeprazole has demonstrated bioequivalence to the respective monotherapies and may improve adherence to anti-inflammatory therapy 6.