NSAIDs: Who is at risk?

Last updated: October 08, 2018

NSAIDs can cause a range of GI side effects such as gastritis, dyspepsia, abdominal pain, vomiting and flatulence. However, some patients are at higher risk of serious harm such as ulcers and GI bleeding:


Over 65 years old


  • The ability of the GI tract to resist damage and to heal decreases with advancing age. So although we are focusing on the over 65s, NSAIDs should be prescribed with caution in any older person. Being older also makes it more likely that a patient will have at least one of the other risk factors below. In addition, elderly patients are more prone to other serious side effects of NSAIDs e.g. on the kidney and cardiovascular system.

Dose and duration of NSAID


  • The GI side effects of NSAIDs are dose-related, and the risk of harm may increase with duration of exposure. Hence, patients who receive high dose NSAIDs and/or long-term therapy are at higher risk. In practice, patients who might be considered for long-term NSAIDs may include those with rheumatoid arthritis or chronic back pain.

Co-administration of other medicines that increase risk of GI bleeding


  • The risk of upper GI bleeding is increased if a non-selective NSAID is prescribed to a patient taking another medicine with significant adverse GI effects such as anticoagulants, antiplatelet aspirin, systemic corticosteroids, and SSRIs. 
  • Concomitant administration of low-dose aspirin with coxibs may also result in an increased rate of significant GI complications, and coxibs can cause bleeding in patients taking warfarin by raising the INR.
  • NICE notes that 'Low-dose aspirin for cardiovascular protection almost always has priority over an NSAID'.

Heavy smoker or alcohol drinker


  • Alcohol causes adverse effects such as gastrointestinal inflammation, whilst tobacco smoking inhibits GI mucosal protective mechanisms, enhances gastric acid output, and increases the risk of H. pylori infection.

Other significant chronic illnesses


  • Studies show that patients with cardiovascular diseases, diabetes, or renal/hepatic impairment seem to be at higher risk.

History of GI bleed and/or H. pylori positive


  • A prior episode of gastroduodenal ulcer/ bleeding or being currently infected with H. pylori make it more likely a patient will experience significant NSAID-induced GI effects.

Contraindications

Note that NSAIDs and coxibs are contraindicated in any patient with active peptic ulceration or GI bleeding. Manufacturers of NSAIDs state that their products should be avoided in patients with a history of GI bleeding or ulceration, but coxib manufacturers do not.

The manufacturers' prescribing data (or SPC) for every NSAID and coxib can be found on the electronic Medicines Compendium, where other contraindications, side effects, and safety messages can be seen.

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