Marcellus Simadibrata Kolopaking MD PhD Department of Medical Education Division Gastroenterology Department of Internal Medicine Faculty of Medicine University Indonesia Dr.Cipto Mangunkusumo Hospital Jakarta

1. MANAGEMENT OF NSAID
GASTROPATHY
Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta

2. Introduction
 NSAIDs are used throughout the world.
 NSAIDs are associated with significant upper
GI side-effects NSAID gastropathy

3. Epidemiology
 United States:
+ 15 – 20 million people  long-term NSAID
users.
Incidence serious GI complications with NSAID
use :1 - 3 % per year.
Exposure of 10 million patients  100,000 -
300,000 potentially fatal GI complications
annually.

4. Epidemiology
 Indonesia  hospital base data of NSAID
adverse effect :
 Makassar 71%
 Jakarta 62.7%
 Surabaya 61%
 Malang 21% (NSAID 22.6%, Jamu 65.3%, NSAID +
Jamu 12.1%)
 No population data

5. Arachidonic acid
COX-1
(constitutive)
COX-2
(induced by inflammatory stimuli)
Non-selective NSAIDs
• Gastrointestinal cytoprotection
• Platelet activity
• Inflammation
• Pain
• Fever
Prostaglandins Prostaglandins


COX-2 selective NSAIDs
Vane & Botting 1995
NSAIDs inhibit enzim COX (siklooksigenase) enzyme which has
the role in prostaglandinproduction

7. NSAIDs are associated with
significant upper GI side-effects
 Classical NSAIDs account for approximately 20-
25% of all reported drug adverse events.
 It has been estimated that 15-40% of patients
taking NSAIDs experience upper GI symptoms.
 The majority(50%) of patients develop some gastric
erosions after each dose of a classical NSAID, up to
100% patients will demonstrate subepithelial
hemorrhage, and 10-25% of chronic users will
develop a peptic ulcer.
Hazleman 1989; Wolfe et.al. 1986
Hirschowitz 1994; Langman et.al. 1999; Silverstein et.al. 2000; Singh et.al. 1996
Brown & Yeomans 1999; Eliott et.al. 1994; Laine 1996

8. NSAIDs are associated with the risk of serious
upper GI complications, hospitalisation and
mortality
 80% of peptic ulcer-related deaths occur in classical NSAID
users.
 50-60% of NSAID-associated peptic ulcers, presenting for
the first time as a complication, have been silent previously.
 Potentially life-threatening upper GI complications occur in
1-4% of classical NSAID users each year.
 In the USA, NSAID use has accounted for approximately
107.000 hospitalisations and 16.500 deaths per year
Armstrong & Blower 1987
Singh 1998
Wolfe et.al. 1999

10. Table 1. Risk For Serious Gastrointestinal Complications
Related To Use Of Nonsteroidal Antiinflammatory Drugs
NUMBER 95%
OF ODDS CONFIDENCE
CATEGORY STUDIES* RATIO INTERVAL
Overall 16 2.74 2.54–2.97
Patient > 60 years old 8 5.52 4.63–6.60
Patient < 60 years old 3 1.65 1.08–2.53
Gastrointestinal bleeding 9 2.39 2.11–2.70
Gastrointestinal surgery 3 7.75 5.83–10.31
Gastrointestinal cause of death 4 4.79 3.64–6.22
*Data derived from metaanalysis of 16 casecontrol and cohort studies.
Modified from Gabriel S. Jaakkimainen L. Bombardier C. Risk for serious gastrointestinal
complications related to use of nonsteroidal antiinflammatory drugs. A metaanalysis. Ann
intern Med 1991; 115: 787.

11. Patient’s Risk Factor for GI complications
 High risk:
- History of peptic ulcer with complication
- Multiple(>2) risk factors
 Moderate risk:
- Age > 65 yo
- High dose NSAID therapy
- History of ulcer without complication
- Uses of aspirin, corticosteroid or anticoagulat
 Low risk:
- Without risk factor
Konsensus Gastropati OAINS 2010

12. Patient’s Risk Factor for GI complications
 High risk:
- History of peptic ulcer with complication
- Multiple(>2) risk factors
 Moderate risk:
- Age > 65 yo
- High dose NSAID therapy
- History of ulcer without complication
- Uses of aspirin, corticosteroid or anticoagulat
 Low risk:
- Without risk factor
Konsensus Gastropati OAINS 2010

18. Long-term Risks of Peptic Ulcers
Associated With Helicobacter pylori
Infection and NSAIDs
 Study design/methods.
183 cases with peptic ulcers and 730 controls (1:4)
 Results.
H pylori infection is associated with an elevated risk of peptic ulcers (OR:
1.95, 95% CI: 1.38-2.74).
Compared to no NSAIDs, any NSAID use (OR: 1.54, 95% CI: 1.06-2.23)
increases the risk of peptic ulcers.
There is also a significant interaction between NSAIDs and H pylori (P =
.047 for interaction of H pylori and increasing quartiles of NSAID use).
 Conclusion.
H pylori infection and NSAID use increase the risks of peptic ulcers.The
ulcer risk associated with NSAID use among H pylori-negative subjects is
greater than that for those with H pylori infection.
Lew et.al. http://cme.medscape.com/viewarticle/490253_12

19. Definition of NSAID
Gastropathy
 NSAID gastroduodenopathy: acute mucosal
lesion of the gaster & duodenum due to
Nonsteroidal antiinflammatory
drugs(NSAID): hyperemia, erosions & ulcer
 Peptic ulcer: ulceration of the gaster &
duodenum related to acid – pepsin & other
agresive factors

20. Pathophysiology of NSAID
Gastropathy
- NSAID/ASA topical: GI mucosal damage
systemic: decreased prostaglandin COX-1
- Adenosine diphopsphate receptor antagonist(clopidogrel)
 inhibit gastric ulcer healing  inhibit platelet/VEGF
release
Konsensus gastropati OAINS 2010

21. ETIOLOGY OF NSAID GASTROPATHY
 Etiology : NSAID  agresive factor
 Imbalance of agresive factor and defensive
factor

22. Agressive factors Defensive factors
-Gastric acid -Mucosal blood flow
-Pepsin -Surface epithelial cell
-Bile reflux -Prostaglandin
-Niotine -Phospholipid/surfactan
-NSAID -Mucus
-Corticosteroid -Bicarbonat
-Helicobacter pylori -Motility
-Stress -Mucosal impermeability to H+
-Chemical -Intracell pH regulation
Normal balance of aggressive factors & defensive factors in normal stomach

24. Hiraishi H et al., Mebio 1994;11(19):86 (Japanese)
Phospholipase
LipoxygenaseCyclooxygenase
NSAIDs
Phospholipid
Arachidonic acid
Decrease of PGs
Decrease mucosal
defense
Mucus reduction
Decrease of HCO3
- secretion
Microcirculation injury
Gastric mucosal injury
Increase of LTs
Increase free radicals
Ischemia-reperfusion
Neutrophil activation
H+ dependent pathway
Accumulation in cells
Directly damage cells
Vasospasm
LTC4
LTD4
LTB4
Liposoluble
Inhibition
Free radicals play an important role in
NSAIDs-induced gastric mucosal injuries

25. Aspirin
and other
NSAIDs
PROTECTIVE
FACTORS
Mucus layer
Ionic gradient
Bicarbonate layer
Prostaglandins
Surface epithelial
cells
Mucosal blood
supply
H. pylori
PepsinGastric
acid
AGGRESSIVE FACTORS
Aspirin and
other NSAIDs
Prostaglandin
production
Bicarbonate
production
Mucus
production
Acidic
environment
Neutral environment
Gastric acid plays a central role in
NSAID-associated gastroduodenal damage

26. CLINICAL MANIFESTATION OF NSAID
GASTROPATHY
 No symptom
 Dyspepsia: epigastric pain, epigastric
discomfort, bloating, early satiety, vomitus,
nausea, belching etc
 Fatigue
 Upper GI bleeding
 Stricture/stenosis
 Acute abdomen: perforation

27. SUPPORTING EXAMINATION
 Pheripheral blood examination, liver function
test, kidney function test, fecal occult blood test.
 H.pylori infection: serology, biopsy culture of the
gastric mukosa, histopathology, CLO test, 14 C
urea breath test, stool antigen
 Esophago-gastroduodenoscopy
 Barium meal X-ray(OMD)

28. Diagnosis of NSAID
Gastropathy
 History of NSAID consumption & dyspepsia
 Physical examination
 Supporting examinations: laboratory,
esophagogastroduodenoskopy examination,
Barium meal(OMD)

29. Diagnostic Evaluation
Gastrics with erosions
Endoscopy
Biopsy
forceps
Cytology
brush

30. ENDOSCOPICAL APPEARANCES
 Lesions: Hyperemia,
erosion & ulcer
 Bleeding: active/not,
oozing, spurting
 Lesions in stomach,
duodenum & jejunum

31. HISTOPATHOLOGICAL ABNORMALITIES
 Subepithelial hemorrhage
 Epithelial thinning & separation
 Mucus thinning & disappearance
 Mucosal erosion & ulcer

32. COMPLICATION OF NSAID
GASTROPATHY
 Obstruction(5%)
 Perforation(<10%)
 Upper GI bleeding(15%): continue to
hypovolemic shock, anemia

33. INDONESIAN CONSENSUS RECOMMENDATIONS
1. GI complications of NSAID (ASA and Non
ASA NSAID)
As the use of NSAID (Including COX-2 selective and
OTC traditional NSAID) in conjunction with cardiac-
dose ASA increase the risk of ulcer complications 
gastroprotective therapy should be prescribed for
at risk patients

34. 2. GI Effects of ASA
 The use of low-dose ASA for cardioprophylaxis is
associated with a two-to four fold increase in in UGI
effects
 Enteric coated or buffered preparation do not
reduce the risk of bleeding
 The risk of UGI effects increases with ASA dose
escalation  for chronic phase of therapy, doses
>81 mg should not be routinely prescribed
 For patients at risk of adverse effects  gastro
protective therapy should be prescribed

35. 3. Gastrointestinal Effect of Combined
ASA and Anticoagulant Therapy
 The combination between ASA & anticoagulant
therapy (including unfractionated heparin,
LMWH,Warfarin) is associated with extracranial
bleeding, and the large proportion is UGI
bleeding
 Patient should receive concomitant PPI as well

36.  In the long term management of ACS, multiple
RCTs show that combination between
anticoagulant therapy and antiplatelet is superior to
anti platelet alone, but it also increase the risk of GI
effect
 A meta analysis of 4 RCTs  unfractionnated
heparin + ASA vs ASA alone for ACS  50%
increase of major bleeding

37. 4. GI Effects of Clopidogrel
 Substitution of clopidogrel (thienopyridine) is
not a recommended strategy to reduce the risk
of recurrent ulcer bleeding in high risk patients
and is inferior to the combination of ASA plus
PPI
 Many studies show that combination between
PPI and clopidogrel decrease the risk of UGI
bleeding compared with clopidogrel alone

38.  Conlicting data exist as to wether PPI diminish the efficacy
of clopidogrel
 The current trials: PRINCIPLES-TIMI 44 (Prasugrel in
comparison to clopidogrel for inhibition of platelet activation
and aggregation thrombolysis in myocardial infarction) and
TRITON-TIMI 38 (Trial to Assess Improvement inTherapeutic
Outcomes by optimizing Platelet Inhibition with Prasugrel-
Thrombolysis in Myocardial Infarction)

 Assessed the association between PPI use, platelet function
and clinical outcomes for patient treated with clopidogrel or
prasugrel  PPIs do not diminish antiplatelet effect of
clopidogrel or prasugrel

39. 5. GI Effects of Combination Between
Clopidogrel and Anticoagulant Therapy
 The combination of clopidogrel and warfarin
therapy  greater risk of bleeding, compared
with monotherapy alone
 use of combination antiplatelet and
anticoagulant therapy should be considered only
in cases which the benefits are likely to outweigh
the risk

40. 6. Treatment and Prevention of
NSAID Gastropathy
 PPI are the preferred agents for the therapy and
prophylaxis of NSAID (including ASA) GI-injury
 Goal of treatment :
 To relief the symptoms
 To heal the lession
 To prevent ulcer and complication
 To prevent ulcer reccurence

41. Prevention
  NSAID + PPI/Misoprostol
  Less side effect NSAID
 Misoprostol (synthetic prostaglandin
analogue)
 effective in the prevention of NSAID
Gastropathy, but it has more side effects
as abdominal cramp and diarrhea

42. Patient with NSAID or antiplatelet (ASA or clopidogrel) consumption
Evaluate gastrointestinal risk factors
Gastrointestinal bleeding
Dual antiplatelet therapy
Anticoagulant therapy
History of complicated ulcer
History of ulcer without bleeding
Upper and/or Low GI Endoscopy
(if facility available)
More than 1 risk factor:
Age ≥ 65 yo
Corticosteroid consumption
Dyspepsia or GERD
PPI+rebamipide/misoprostol*** PPI/rebamipide/misoprostol***
UpperGI Ulcer
H. Pylori test
(UBT, HpSA)
If (+) therapy
PPI/rebamipide/misoprostol***
TREATMENT AND PREVENTIONOF NSAID GASTROENTEROPATHY
Yes
Yes
Yes
Yes No
No

43. PATIENT RISKS FOR GASTROINTESTINAL
COMPLICATIONS
• High risk:
1. History of complicated ulcer
2. Multiple of risks(>2)
• Moderate risk:
1. Age > 65 yo
2. High dose NSAID treatment
3. History of non complicated ulcer
4. Consumption: Aspirin, corticosteroid, anticoagulan
• Low risk:
1.Without risk factor
National consensus 2011 on the management of NSAID
Gastroenteropathy in Indonesia. Jakarta

44. SUMMARY OF THE RECOMMENDATION PREVENTION OF NSAID GASTROENTEROPATHY
Gastrointestinal Risks
Mild Moderate Severe
CV Risks
low*
NSAID +
rebamipide/
misoprostol***
NSAID + PPI/
rebamipide /
misoprostol***
Alternative
therapy or COX2
inhibitor +PPI /
rebamipide /
misoprostol***
CV Risks
high**
Naproxen +
PPI/rebamipide/
misoprostol***
Naproxen +
PPI/rebamipide/
misoprostol***
Avoid NSAID or
COX2 inhibitor,
Alternative therapy
*Cardiovascular Risks (CV) low: do not need low dose aspirin / clopidogrel
** Cardiovascular Risks(CV) high: need low dose aspirin / clopidogrel
*** Misoprostol frequently caused side effects diarrhea and abdominal cramp.

45. Many RCTs showed:
 Lansoprazole is more effective than ranitidine
 Lansoprazole is more effective than omperazole
 in the prevention and treatment of NSAID
gastropathy and in the prevention of ulcer
reccurency
 Effectivity of other PPI in the management of
NSAID gastropathy required further data

46. Figure. Healing rate of NSAID-associated
gastric ulcer
Maeda dkk. 1998. Therapeutic Research
22/52 (42.3)
4 8
50
100
Healingrate
Weeks
: H2 blocker (52 lesions)
: H2 blocker + cytoprotective drugs(52 lesions)
: PPI (62 lesions)
(%)
31/62 (50.0)
50/62 (80.6)
32/52 (61.5)
( ) : %
33/103 (32.0)
70/103 (68.0)

47. Figure. Healing rate of NSAID-associated gastric
ulcer (Omeprazole vs Lansoprazole)
Maeda dkk. 1998.Therapeutic Research
4 8
50
100
Healingrate
Weeks
: Omeprazole (25 lesions)
: Lansoprazole (37 lesions)
(%)
20/37 (54.1)
11/25 (44.0)
32/37 (86.5)
18/25 (72.0)
( ) : %

48. Figure. Cumulative rates of healing at 4 and 8 weeks during
treatment with ranitidine hydrochloride, 150 mg twice daily;
15 mg once daily; or lansoprazole, 30 mg once daily, among
intent-to-treat patients
Naurang. et al. 2000. Arch Intern Med
4 8
50
100
(%)Healed
Week
: Ranitidine Hydrochloride
: Lansoprazole, 15 mg
: Lansoprazole, 30 mg
(%)
40
90
30
80
20
70
10
60
Gastric ulcers

49. Pharmacokinetic and acid inhibition
profiles
Efficacy
Indications and formulations
Potential for drug interactions
Tolerability/safety
Choosing a PPI to manage acid related diseases:
factors to be considered

50. Tolman et al,J Clin Gastroenterol 1997; 24: 65–70.
Howden et al, Clin Pharmacokinet 1991; 20: 38–49.
Hassan-Alin et al, Eur J Clin Pharmacol 2000; 56: 665–70.
Omeprazole has up to 40% bioavailability after
first dose
l Progressive increase in bioavailability (to
about 60%) and antisecretory effect to
day 5
Lansoprazole bioavailability is 85% after first
dose
Esomeprazole bioavailability is 64% after first
dose; half-life similar to omeprazole
Bioavailability of PPIs

51. Bioavailability(%)
Tolman et al,J Clin Gastroenterol 1997; 24: 65–70.
Fitton &Wiseman, Drugs 1996; 51: 460–82.
Hassan-Alin et al,Gastroenterology 2000; 118:A16.
Swan et al., Aliment PharmacolTher 1999; 13(Suppl 3): 11–7.
Howden, Clin Pharmacokinet 1991; 20: 38–49.
PPI bioavailability after the first dose
80
90
80
70
60
50
40
30
20
10
0
Lansoprazole Pantoprazole Esomeprazole Rabeprazole Omeprazole
77
64
52
40

53. Tolman et al., J Clin Gastroenterol 1997; 24: 65–70.
Mean24-hgastricpH
5
Pre-regimen Day 1 Day 5
4
2
0
**
**
Lansoprazole 30 mg once daily
Omeprazole 20 mg once daily
Double-blind crossover study in 14
healthy volunteers
**p<0.002 after first and fifth doses
Speed of onset of PPI-induced
acid suppression
3
1

54. Thoring et al., Scand J Gastroenterol 1999; 34: 341–5.
n=15, crossover
study healthy
volunteers
300
200
0
TimetoreachpH>4(minutes)
130
250
Lansoprazole
30 mg
100
Omeprazole
20 mg
Time to acid suppression:
lansoprazole vs omeprazole

55. Mean time
to pH 4
(hours:minutes)
Difference (minutes) p-value
Lansoprazole 30 mg 1:29
-7 0.70
Esomeprazole 40 mg 1:22
Lansoprazole 15 mg 1:50
16 0.48
Esomeprazole 20 mg 2:06
Eriksson et al., Scand J Gastroenterol 2001; 36(Suppl 233): 49.
Equivalent speed of onset of acid
suppression: lansoprazole and esomeprazole

56. Esomeprazole 40 mg IV satu kali sehari lebih cepat dan lebih efektif mengontrol
keasaman lambung dibandingkan pantoprazole 40 mg IV

57. Drug tested Lansoprazole Omeprazole Esomeprazole Pantoprazole Rabeprazole
Phenytoin No Yes No No No
Warfarin No Yes No No No
Diazepam No Yes Yes No No
Prednisone No No NT NT NT
Oral contraceptive No No NT No NT
Propranolol No No NT NT NT
Metoprolol NT NT NT No NT
Theophylline No No NT No No
Parsons et al., Eur Gastro Hepatol 1996; 8(Suppl 1): S15–20; Fitton &Wiseman, Drugs 1996; 51: 460–82. Freston, AmJ
Gastroenterol 1997; 92(Suppl 4): S51–5; Humphries et al., Gut 1996; 39(Suppl 3): 297.
Pan et al., Gastroenterology 1999; 116:A276; Nexium Prescribing Information, 2001.
Henry et al., Eur J Clin Pharmacol 1987; 33: 369–73; Karol et al., J Clin Pharmacol 2000; 40: 301–8.
NT = not tested
Interactions between PPIs
and other drugs

59. 7. Role of H. pylori
 Testing for and eradicating H. pylori in patient
with history of ulcer disease is recommended
before starting NSAID/Antiplatelet therapy

60. Both H. pylori infection and NSAID use
independently and significantly increase
the risk of peptic ulcer and ulcer bleeding
H. pylori infection and NSAID use are
synergistic for peptic ulcer development
and ulcer bleeding
Huang et al., Lancet 2002; 359: 14–22.

64. Intragastric pH with high-dose
iv PPI therapy
 Clinical pharmacology studies
 H. pylori-negative healthy volunteers
 24 hour iv infusion
1Röhss K, et al. Intl J Clin PharmTher 2007;45:345–54; 2Metz DC, et al. Aliment PharmacolTher 2006;23:985–95
n Median/mean Time pH>6
24-hour pH (0–24 hours)
Esomeprazole
80 mg + 8 mg/hour1 25 5.8 12.6
Pantoprazole
80 mg + 8 mg/hour2 36 5.0 5.5–6.7
*This is not “ a head to head” study

65. 8. Discontinuation of Antiplatelet
Therapy Because of Bleeding
  decision for discontinuation of ASA in the
setting of acute ulcer bleeding must be made on
an individual basis, based upon cardiac risk and
GI risk assessment to discern potential
thrombotic and hemorraghic complication
 There is no evidence that non-ASA anti
platelet drug such as clopidogrel will reduce
bleeding risk in the presence of active ulcers

66. 9. Endoscopy in patients on mono
or dual antiplatelet therapy
  Endoscopic therapy may be performed in
high risk cardiovascular patients on dual
antiplatelet therapy, and collaboration between
the cardiologist and endoscopist should be
balance the risk of bleeding with thrombosis,
with regard to the timing of cessation of
antiplatelet therapy

70. Conclusion
 NSAID Gastroduodenopathy is one of
important problems in daily clinical practice.
 There are some risk factors which correlated
to NSAID ulcers complications.
 The treatment and prevention of NSAID
gastropathy  Proton Pump Inhibitor.
 The most effective and safe PPI for the
treatment and prevention of NSAID
gastropathy is Esomeprazole.