The stomach is a resilient organ with an amazing ability to maintain and repair itself. There are a number of physiological processes occurring within the stomach that allow it to rapidly repair damage when it does occur. The frequent discussions regarding the administration of NSAIDs and their capacity to cause GI bleeds has not deterred the average patient from taking these products without much thought as to the risks they carry.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used by physicians to treat patients with a variety of inflammatory and non-inflammatory conditions. They are the most commonly prescribed drug class, with more than 100 million prescriptions written each year(1). Billions of dollars are spent each year on prescription NSAIDs despite their dangerous side effect profiles, and these only account for about 10% of all NSAID use, the remainder being over the counter.

NSAIDs are associated with significant drug related morbidity and mortality.  In the late 1990’s it was estimated 16,500 died and over 100,000 were hospitalized from NSAID induced GI bleeds(2).  This complication accounted for 1/3 of the total cost of arthritis care(3,4).  Patients over the age of 65, with concomitant medications and disease states are the most likely to suffer the adverse side effects associated with NSAID use(5). Alternative medications to NSAIDs to treat pain have problems as well.  Narcotic analgesics, although effective, have high addictive potential, are sedating, cause constipation, and urinary retention.  Tricyclic antidepressants, dual reuptake inhibitors, anti epileptics, and others commonly used to treat neuropathic pain and chronic musculoskeletal pain have a long list of harmful side effects, all of which often far outweigh their perceived benefit.

NSAIDs block prostaglandin synthesis, and should be classified more as an anti-prostaglandin agent rather than an anti-inflammatory agent. NSAIDs have actually been shown to increase inflammation within the body (6). The inhibitory effects of an NSAID are due to their ability to block prostaglandin production, thus blocking the production of long acting pain signaling chemicals. Inhibiting prostaglandin production has a very dire unintended consequence for many patients, and that is the rapid demise of the gastric mucosal defense system.

Prostaglandins modulate virtually every aspect of mucosal defense. It is widely understood that mucosal prostaglandin deficiency increases susceptibility to ulcer formation and that exogenous administration of supplemental prostaglandins reduces ulcer risk. Continued NSAID use endangers the lining of the stomach, and prevents the body from naturally repairing itself. Physicians and patients interested in pain management must be aware of these facts, so that they can make an informed decision as to what medications are appropriate for them to use and for what duration.  It is vital that patients understand the mechanisms by which the drugs they take affect their body in order to achieve effective and safe healthcare.

1. http://www.medscape.com/viewarticle/538039
2. Wolff M, Lichtenstein D, Singh G.  Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs.  N Engl J Med. 1999; 340(24):1888-99.
3. Johnson R, Hornbrook M, Hooker R, et al.  Analysis of the costs of NSAID-associated gastropathy.  Experience in a US health maintenance organization.  Pharmacoeconomics.  1997; 12(1):76-88.
4. Sheen C, MacDonald T.  Gastrointestinal side effects of NSAIDs-pharmacoeconomic implications.  Expert Opin Pharmacotherapy.  2002; 3(3):265-9.
5. Burmester G, Lanas A, Biasucci L, et al.  The appropriate use of non-steroidal anti-inflammatory drugs in rheumatic disease:  opinions of a multidisciplinary European expert panel.  Ann Rheum Dis.  2011; 70(5):818-22.
6. http://journals.lww.com/americantherapeutics/Abstract/publishahead/A_Double_Blind_Controlled_Trial_of_a_Single_Dose.99686.aspx