Prevention of NSAID-Induced Ulcers by the Coadministration of Misoprostol: Implications in Clinical Practice

Abstract

The guiding principle of ulcer therapy for many years has been “No acid, no ulcer” and many still adhere to it. Nonsteroidal anti-inflammatory drugs (NSAIDs) appear to cause ulcers primarily through prostaglandin depletion rather than through an acid-based mechanism. These ulcers affect a large number of patients and give few warning signs, often none, until it is too late. The profound relief offered to arthritis patients by NSAIDs, in the absence of equally effective remedies, means that rheumatologists must continue to deal with specific and quantifiable risks of NSAID-related gastrointestinal (GI) ulceration and its associated complications. The prostaglandin analog, misoprostol. may address many of these concerns because it reverses the patient's prostaglandin depleted condition. It is effective in preventing NSAID-induced ulcers, and does not interfere with the desired analgesic or anti-inllammatory effects of NSAIDs. The tools to assess the risk of NSAID-related hospitalization or death due to GI complications are available and patients at greatest risk can be identified. Physicians whose patients are at risk may wish to consider therapy with misoprostol 400 to 800 μg/day in divided doses. It is recommended that misoprostol be coadministered with the NSAID after meals. The most common side effects that the patient may experience arc some mild and transient diarrhea and cramps upon initiation of misoprostol therapy and these can be minimized by taking misoprostol with meals and avoiding magnesium-containing antacids. For misoprostol's protective role to be demonstrated, it should be coprescribed with the NSAID for the duration of the NSAID therapy. It has no reported interaction with drugs commonly used to treat cardiovascular, gastrointestinal, pulmonary, or nervous system diseases, and the dosage requires no adjustment for elderly patients or those with renal or hepatic impairment.

Key Words:

• H₂-blockers
• proton-pump inhibitors
• sucralfate
• NSAID-induced gastropathy