Intestinal Damage by Anti-inflammatory Agents

Abstract

Non steroidal anti-inflammatory drugs (NSAIDs) are one of the most successful classes of therapeutic agents ever marketed. Hence their adverse effects on the gastrointestinal (GI) tract have become the commonest and most important cause of medically induced iatrogenic GI disease. Unfortunately, the medical community has been lulled into a misunderstanding of the GI site that most commonly suffers complications in patients on NSAIDs. To a large extent this is the consequence of the ‘intestinal myopia’ which results from the widespread availability of upper GI endoscopes, which rarely progress further than the second part of the duodenum. The ease with which gastroduodenal ulceration can be visualised is emphasised by the dramatic consequences of haemorrhage from a bleeding ulcer. In itself this is certainly a most significant clinical problem. It has been estimated that for every 500–800 prescriptions of NSAIDs, one patient experiences catastrophic GI complications in the shape of haemorrhage or perforation from a peptic ulcer (totalling 30,000–40,000 patients annually in the United Kingdom, and this results in a 10% mortality risk [3, 6, 33, 34, 38, 71]. However, these factors have concealed the fact that the small intestine is the commonest site of NSAID toxicity, resulting in considerable morbidity (and mortality) in chronic users of the drugs.