Review article: a practical approach to the clinical management of NSAID enteropathy

Abstract

Co-prescription of acid suppressive therapy, together with advances in small bowel imaging techniques, have shifted the burden of NSAID-related toxicity from gastro-duodenal to more distal small bowel injury. Due to predominantly subclinical disease, NSAID enteropathy remains under-recognised, with an incidence of 53–80% amongst healthy short-term users, and a prevalence of 50–71% following long-term (>3 months) use. Despite their distinct pathogenesis, those at risk of NSAID-related gastro-duodenal and small bowel complications share several risk factors. Clinical complications of NSAID enteropathy such as protein-losing enteropathy, small bowel strictures and diaphragm disease, confer significant morbidity, and are often irreversible. Small bowel prophylaxis has proven of modest efficacy after short-term, high-dose NSAID use in asymptomatic patients. While selective COX-2 inhibitors are associated with fewer gastro-duodenal complications relative to non-selective NSAIDs, their comparative benefit in protecting against small bowel enteropathy remains unclear. Prophylaxis should be considered in those at high risk of small bowel complications, as treatment options for established disease remain limited; however, the optimal agent remains unclear. We propose a clinical algorithm that may help prevent, monitor, investigate, and manage the sequelae of NSAID-induced small bowel toxicity.

Keywords:

• NSAID enteropathy
• small bowel
• COX-1/COX-2 inhibition
• pathogenesis
• prophylaxis
• risk factors
• diaphragm disease
• capsule endoscopy

Acknowledgements

We would like to acknowledge Professor Neville Yeomans for his critical appraisal of our manuscript.

PDC is supported by a David Bickart Clinician Research award from the University of Melbourne and a Bushell Postdoctoral award from the Gastroenterological Society of Australia (GESA).

Disclosure statement

PDC has received educational support, consulted on advisory boards, and been a speaker at educational symposia sponsored by Shire, Ferring, Janssen, Takeda, AbbVie, and Baxter.