COX-2 inhibitor, PPI combo best for avoiding NSAID-associated GI toxicity

Last Updated: 2016-05-27

By Will Boggs MD

NEW YORK (Reuters Health) - The best strategy for preventing NSAID-associated gastrointestinal toxicity is to combine selective COX-2 inhibitors with proton pump inhibitors (PPIs), researchers have found.

"The combination of selective COX-2 inhibitors plus PPIs provides the best gastrointestinal protection, followed by selective COX-2 inhibitors and nonselective NSAIDs plus PPIs," Dr. Jin-Qiu Yuan from The Chinese University of Hong Kong told Reuters Health by email. "These strategies also show favorable tolerability."

Recognized strategies for preventing NSAID-associated GI toxicity include co-prescription of gastroprotective agents (PPIs, misoprostol, and histamine-2 receptor antagonists (H2RAs)) with COX-2 inhibitors, but it is unclear which of these strategies is safest and most effective.

Dr. Yuan and colleagues evaluated the comparative effectiveness and safety of current strategies for preventing NSAID-associated gastrointestinal toxicity in a systematic review and network meta-analysis of 82 trials including more than 125,000 patients.

They examined five strategies: selective COX-2 inhibitors, nonselective NSAIDs plus PPIs, nonselective NSAIDs plus misoprostol, nonselective NSAIDs plus H2RAs, and selective COX-2 inhibitors plus PPIs.

Selective COX-2 inhibitors plus PPIs were associated with the lowest risk of ulcers (0%) and ulcer complications (0.04%), followed by selective COX-2 inhibitors and nonselective NSAIDs plus PPIs.

Nonselective NSAIDs plus H2RAs was the least effective strategy for preventing ulcer complications, according to the report, online April 28 in Alimentary Pharmacology and Therapeutics.

The rate of adverse event-related withdrawals was lower with nonselective NSAIDs than with selective COX-2 inhibitors and nonselective NSAIDs plus PPIs and nonselective NSAIDs plus misoprostol.

When ulcer complication rates and adverse event-related withdrawals were combined, selective COX-2 inhibitors plus PPIs, selective COX-2 inhibitors, and nonselective NSAIDs plus PPIs tended to have more optimal effectiveness and tolerance outcomes.

"GI safety is only one of the issues that need to be considered," Dr. Yuan said. "Clinicians should also consider the cardiovascular risk, costs, patients' preference, and interaction with other medicine (such as COX-2 inhibitors and aspirin) in decision making."

"COX-2 inhibitors should be used cautiously," he added, "as evidence has indicated that they may increase the cardiovascular risk."

SOURCE: http://bit.ly/1seQdIL

Aliment Pharmacol Ther 2016.