Recommendations for the appropriate use of anti-inflammatory drugs in the era of the coxibs: defining the role of gastroprotective agents.
Treatment with anti-inflammatory drugs and the analgesic efficacy of conventional nonsteroidal anti-inflammatory drugs (NSAIDs) are compromised by a two- to fourfold increased risk of gastrointestinal complications. This increased risk has resulted in an increasing use of the new selective cyclooxygenase-2 inhibitors or coxibs, which, in clinical trials and outcomes studies, reduced gastrointestinal adverse events by 50% to 65% compared with conventional NSAIDs. However, the coxibs are not available to all patients who need them, and NSAIDs are still widely used. Moreover, treatment with a coxib cannot heal pre-existing gastrointestinal lesions, and cotherapy with an anti-secretory drug or mucosal protective agent may be required. This paper addresses the management of patients with risk factors for gastrointestinal complications who are taking NSAIDs and makes recommendations for the appropriate use of 'gastroprotective' agents (GPAs) in patients who need to take an NSAID or a coxib. When economically possible, a coxib alone is preferable to a conventional NSAID plus a GPA to minimize exposure to potential gastrointestinal damage and avoid unnecessary dual therapy. Patients at high risk require a GPA in addition to a coxib.
Hunt
Richard H
RH
Division of Gastroenterology, Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario. huntr@fhs.mcmaster.ca
Barkun
Alan N
AN
Baron
David
D
Bombardier
Claire
C
Bursey
Ford R
FR
Marshall
John R
JR
Morgan
David G
DG
Paré
Pierre
P
Thomson
Alan B R
AB
Whittaker
J Scott
JS
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000191:economics / Q000592:standards* / Q000627:therapeutic use*; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D001241:Aspirin / Q000592:standards / Q000627:therapeutic use; D016861:Cyclooxygenase Inhibitors / Q000592:standards / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D005767:Gastrointestinal Diseases / Q000188:drug therapy* / Q000401:mortality / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D007783:Lactones / Q000592:standards* / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012307:Risk Factors; D013450:Sulfones; D016896:Treatment Outcome
D000894:Anti-Inflammatory Agents, Non-Steroidal; D000897:Anti-Ulcer Agents; D016861:Cyclooxygenase Inhibitors; D007783:Lactones; D013450:Sulfones; C116926:rofecoxib; D001241:Aspirin