title: Comparing rates of dyspepsia with Coxibs vs NSAID+PPI: a meta-analysis.
abstract: OBJECTIVE
  Because dyspeptic symptoms are far more prevalent than ulcer complications in users of nonsteroidal anti-inflammatory drugs (NSAIDs), economic models indicate that dyspepsia rates (not ulcer complications) are the major determinant of cost-effectiveness in treating arthritis. We performed a meta-analysis to compare rates of dyspepsia for two common therapies in high-risk patients with arthritis: cyclooxygenase-2 inhibitor (Coxib) alone and combination therapy with a nonselective NSAID and a proton pump inhibitor (PPI) (NSAID+PPI).
  
  
  METHODS
  We performed a systematic review to identify trials comparing either a Coxib versus NSAID or NSAID+PPI versus NSAID in chronic arthritis. We selected studies that report incident dyspepsia, defined a priori as "epigastric pain," "dyspepsia," and "nausea." We then performed meta-analysis to compare the relative risk reduction and absolute risk reduction of dyspepsia for Coxib versus NSAID and NSAID+PPI versus NSAID.
  
  
  RESULTS
  Meta-analysis of 26 studies comparing dyspepsia between Coxibs and NSAIDs revealed a 12% relative risk reduction for Coxibs with an absolute risk reduction of 3.7%. Meta-analysis of four studies comparing dyspepsia between the NSAID+PPI combination and NSAIDs alone revealed a 66% relative risk reduction for NSAID+PPI with an absolute risk reduction of 9%. Compared with the NSAID strategy, the number needed to treat to prevent dyspepsia was 27 for Coxibs and 11 for NSAID+PPI.
  
  
  CONCLUSIONS
  NSAID+PPI affords greater risk reduction for dyspepsia than Coxibs when compared with the common baseline of NSAIDs. Because there are limited head-to-head data comparing Coxibs versus NSAID+PPI, these data provide the best indirect evidence that NSAID+PPI may be superior to Coxibs in minimizing incident dyspepsia.
authors.affiliation: Division of Gastroenterology and Hepatology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, Calif 90073, USA. bspiegel@mednet.ucla.edu
authors.forename: Brennan M R
authors.initials: BM
authors.lastname: Spiegel
authors.forename: Mary
authors.initials: M
authors.lastname: Farid
authors.forename: Gareth S
authors.initials: GS
authors.lastname: Dulai
authors.forename: Ian M
authors.initials: IM
authors.lastname: Gralnek
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000627:therapeutic use; D001168:Arthritis / Q000188:drug therapy; D052246:Cyclooxygenase 2 Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004415:Dyspepsia / Q000139:chemically induced* / Q000453:epidemiology; D004791:Enzyme Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D054328:Proton Pump Inhibitors; D012307:Risk Factors
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D004791:Enzyme Inhibitors; D054328:Proton Pump Inhibitors