Management of High-risk Patients on Non-steroidal Anti-inflammatory Drugs or Aspirin
- 53 Downloads
Low-dose aspirin is increasingly used for the primary prevention of cardiovascular events. However, current evidence suggests that the gastrointestinal and other bleeding risks of aspirin probably outweigh its potential benefits in primary prevention. Various strategies have been proposed to reduce the gastrointestinal risk of aspirin, including gastroprotection with a proton pump inhibitor (PPI), eradication of Helicobacter pylori infection and replacing aspirin with other anti-platelet agents. Although co-therapy with a PPI and the eradication of H. pylori substantially reduce the risk of recurrent ulcer bleeding with aspirin, the replacement of aspirin by clopidogrel cannot be recommended to patients with a high gastrointestinal risk. Traditionally, strategies for the prevention of non-steroidal anti-inflammatory drug (NSAID)-induced ulcer complications included co-therapy with a gastroprotective agent and the substitution of cyclooxygenase (COX)-2 inhibitors for non-selective NSAID. Evidence emerged recently that COX-2 inhibitors and some non-selective NSAID increase cardiovascular risk. Before prescribing anti-inflammatory therapy, both gastrointestinal and cardiovascular risk factors of individual patients need to be evaluated. In patients with increased cardiovascular risk requiring anti-inflammatory analgesics, the combination of a non-selective NSAID, low-dose aspirin and a PPI is the preferred treatment.
KeywordsAspirin Clopidogrel Celecoxib Proton Pump Inhibitor Lansoprazole
Unable to display preview. Download preview PDF.
- 3.Pearson TA, Blair SN, Daniels SR, et al. AHA Guidelines for primary prevention of cardiovascular disease and stroke, 2002 update. Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002; 106: 388–91PubMedCrossRefGoogle Scholar
- 11.Chan FKL, Ching JYL, Suen CBY, et al. Eradication of H. pylori for the prevention of recurrent ulcer bleeding in high-risk aspirin users: a 4-year prospective cohort study [Abstract]. Gastroenterology 2005; 128 suppl: A133Google Scholar
- 12.Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction — summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002; 40: 1366–74PubMedCrossRefGoogle Scholar
- 13.Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina) 2002. Available from: http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm. Cited: 4 October 2005.
- 17.Goldstein JL, Joseph-Ridge N, MacDonald PA, et al. Lansoprazole provides gastroprotection in high-risk arthritis patients taking daily aspirin and chronic NSAIDS [Abstract]. Pharmacotherapy 2003; 23: 71EGoogle Scholar
- 18.Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA 2000; 284: 1247–55PubMedCrossRefGoogle Scholar
- 22.Scheiman JM, Vakil N, Hawkey CJ, et al. Esomeprazole prevents gastric and duodenal ulcers in at-risk patients on continuous non-selective or COX-2-selective NSAID therapy [Abstract]. Gastroenterology 2004; 126 suppl. 1: A–82Google Scholar