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Drug-Induced Peptic Ulcer Disease

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Drug-Induced Peptic Ulcer Disease View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by OAR@UM risk populations only.7 The prevalence of endoscopically confirmed gastrointestinal ulcers in NSAID users is quoted to be between 15% and 30%. Between 12% to 30% of NSAID-induced ulcers are gastric ulcers, whereas 2% to 19% are duodenal ulcers. NSAID-induced ulcers are symptomatic only in 1% of patients after three to six months and in 2 to 4% of patients after one year. Inappropriately they do not correlate well with pain because the analgesic action of NSAIDs may mask the ulcer pain.2 Drug-induced peptic Understanding the method by which NSAIDs cause gastric damage has helped in the development of prophylactic agents that ulcer disease 1 red uce their toxicity. The mechanism by which NSAIDs are thought to damage the Valerie Vella B Pharm(Hons), PgDip Clin Pharm (Aberdeen) gastrointestinal tract is four-fold. Clinical Pharmacist, St Luke’s Hospital, Guardamangia, Malta a) Topical injury Email: [email protected] Originally it was thought that NSAIDs damaged the gastric epithelium by Key words: Peptic ulcer, medicines, prostaglandins, gastrointestinal protection, intracellular accumulation of these drugs in gastrointestinal toxicity an ionised state.1 However the fact that enteric-coated formulations, pro-drugs, For more than a century, peptic ulcer disease has been a rectal and parenteral administration of 1 major cause of morbidity and mortality. Peptic ulcer disease NSAIDs still resulted in gastrointestinal is a heterogeneous group of disorders involving the damage despite the apparent absence of gastrointestinal tract and results from an imbalance between direct mucosal contact implies a minor role the aggressive forces of gastric acid and pepsin and the for topical injury1,2. defensive mechanisms of the gastric mucosa.1,2,3 b) Inhibition of prostaglandin synthesis In 1971 Vane discovered that NSAIDs act by the inhibition of cyclooxygenase the Introduction supplements, corticosteriods, anticoagulants enzyme that converts arachidonic acid to Following the discovery of the and chemotherapy play a role. prostaglandins. As prostaglandins play a association of peptic ulcer disease with major role in the maintenance of Helicobacter pylori infection there has been Non-steroidal anti-inflammatory gastroduodenal defence mechanisms; their a decline in the prevalence of drugs (NSAIDs) depletion due to NSAIDs and aspirin impairs uncomplicated peptic ulcer disease. In Commonly prescribed for a variety of cytoprotection resulting in mucosal injury, contrast, a striking rise in admissions for musculoskeletal complaints such as erosions and ulceration.1, 8 ulcer haemorrhage and perforation among rheumatoid arthritis and short-term elderly people is now being observed. This management of pain in osteoarthritis, 4,5 c) Nitric Oxide rise has been attributed to the increased NSAIDs are associated with both upper and Recent attention has focused on the use of non-steroidal anti-inflammatory lower gastrointestinal tract complications. role of nitric oxide (NO) in maintenance of drugs (NSAIDs) and low-dose aspirin.1 Drug- Prevalence rates vary significantly6 as gastric-mucosal blood flow.1 Like induced peptic ulcers are not exclusive to estimates do not make a distinction prostaglandins nitric oxide has been shown anti-inflammatory drugs, other medicines between causal and non-causal associations to increase mucosal blood flow, stimulate such as bisphosphonates, potassium or because estimates are observed in high- mucus secretion and inhibit neutrophil Issue 10 Summer 2005 Journal of the Malta College of Pharmacy Practice 15 adherence.1 In animals NO-releasing potential of coxibs demonstrate conflicting acute coronary syndrome.22 The risk of NSAIDs produce less gastric damage than data. 9, 15, 16,17 gastric and duodenal ulcers with clopidogrel their parent drugs and they even promote is between 0.1 – 1.0%.22 Unfortunately ulcer-healing.1,9 Cyclo-oxygenase inhibiting clopidogrel is not a solution to patients who nitric oxide donators are unable to take aspirin because of d) Neutrophil-mediated injury COX-inhibiting nitric oxide donators, gastrointestinal complications. A number of Neutrophil adherence to the CINODs, are a new class of analgesic drugs small studies have in fact revealed that in endothelium of gastric microcirculation designed to provide analgesic efficacy patients with a history of bleeding and damages the mucosa by liberating oxygen- through COX-inhibition and peptic ulcer the combination of aspirin and free radicals, releasing proteases and gastrointestinal safety through the a proton pump inhibitor is safer than obstructing capillary blood flow. NSAIDs protective effects of controlled nitric oxide clopidogrel in terms of bleeding side are thought to stimulate neutrophil donation9,18. AZD3582 was the first CINOD effects.23 adherence by up-regulation of adhesion to enter clinical development.19 Although molecules.1 initial reports were promising, a recent Bisphosphonates The overall result is that NSAIDs cause study has indicated that the much Bisphosphonates such as alendronate, damage as they impair the ability of the expected superior gastrointestinal etidronate and risedronate, are now used gastrointestinal mucosa to respond to tolerability of AZD3582 is no better than extensively in the treatment of patients injury.9 Not all NSAIDs have the same that provided by naproxen.20 with osteoporosis and Paget’s disease and potential to cause peptic ulcer disease, in prophylaxis of osteoporosis.24,25 All fact ibuprofen in low doses (up to 1200mg Aspirin bisphosphonates cause gastrointestinal daily) is said to have the same Odds Ratio2 Aside from its use as an anti- side-effects14,26 however post-marketing as paracetamol in causing upper inflammatory, aspirin in low dose is surveillance indicated that alendronate and gastrointestinal bleeding.7 Diclofenac also frequently indicated for the secondary risedronate are associated with severe has a low odds ratio although higher than prevention of thrombotic cerebrovascular oesophageal reactions and gastric and that for ibuprofen. Indomethacin, or cardiovascular disease.4,5,21 Incidence of duodenal ulceration.14,25,27,28,29 It is unclear naproxen and piroxicam have an peptic ulcers has been reported to be as whether variation in ulcerogenic potential intermediate odds ratio† whereas high as 35%.7 Advising patients to take reflects differences in dosing, formulation azapropazone and ketoprofen, has a very enteric coated tablets or to take the or chemical structure.29 high odds ratio, and should thus be preparation after food may minimise Studies with alendronate indicate that avoided in high-risk patients7, 8,10,11,12,13 gastrointestinal symptoms as dyspepsia, the oesophageal damage is consistent with but as for NSAIDs ulceration is mainly a topical irritant effect.28 Failure of Cyclo-oxygenase (COX 2) attributable to its systemic effect on alendronate tablets to pass through the selective inhibitors prostaglandin synthesis.5 Co-prescription oesophagus may result in prolonged local There are at least two isoforms of of aspirin with standard NSAIDs augments mucosal exposure to the drug, leading to cyclo-oxygenase: COX 1 and COX 2. The the risk of such complications and risk erosive or ulcerative mucosal damage with former is found in high concentrations in reduction of upper gastrointestinal events inflammation and thickening of the platelets, vascular endothelial cells, the associated with COX 2 selective inhibitors oesophageal wall.30 For most part such stomach and in kidney collecting tubules may not be evident when they are reactions can be avoided by appropriate and is responsible for the prostaglandins combined with aspirin.4 administration of the alendronate tablets. which are essential for maintenance of These include swallowing the tablet whole normal endocrine function, renal function, Clopidogrel with plenty of water (not less than 200ml) gastric mucosal integrity and haemostasis.4 Clopidogrel is an antiplatelet drug on an empty stomach at least thirty COX 2 is significantly increased by indicated for the prevention of minutes before food while sitting or inflammatory and mitogenic stimuli. By atherothrombotic events in patients standing. Patients should also be reminded selectively blocking COX 2, COX 2 selective suffering from myocardial infarction, to stand or sit upright for at least one hour inhibitors have a theoretical advantage ischaemic stroke or established peripheral after taking the tablet.31 On the other hand over the traditional NSAIDS with respect to arterial disease.21,22 It is also given in gastroduodenal injury appears to be an red ucti on in GI side-effects.4,14 Published combination with aspirin in patients acute phenomenon not associated with clinical trials assessing the gastroerosive suffering from non-ST segment elevation significant complications, except in high- †Odds ratio (OR) is defined as the odds of an event happening in the experimental group expressed as a proportion of the odds of an event happening in the control group. If OR is greater than one, then the effects of the treatment are more than those of the control treatment. 16 Journal of the Malta College of Pharmacy Practice Issue 10 Summer 2005 risk situations such as the presence of Practice Points motility disorders or concurrent use of NSAIDs or anticoagulants.25 In a small study •Patients should always receive correct •Patients with active peptic ulcers administration instructions.
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