Wilcox and Ladabaum discussed ways to reduce risk of gastrointestinal complications of nonsteroidal anti-inflammatory agents (NSAIDS) in a patient at high risk for these complications. The authors are from the University of Alabama at Birmingham and University of California San Francisco.


Criteria for a high risk patient:

(1) previous gastrointestinal complications

(2) past history of peptic ulcer

(3) older age

(4) concurrent therapy with corticosteroids and/or anticoagulants

(5) high dose NSAID therapy

(6) therapy with multiple NSAIDS


General rules:

(1) Only treat with aspirin and/or NSAIDS if the benefit outweighs the risk.

(2) Consider an alternative agent with lower risk but similar or greater efficacy.

(3) Use the lowest possible dose of the aspirin and/or NSAID for the shortest period of time.

(4) Treat potentially treatable conditions like gastritis with Helicobacter pylori.

(5) It may be necessary to hold the NSAID for several days following acute hemorrhage, but the duration depends on the risk of complications associated with interrupted therapy.


Therapeutic Agent

Cardiovascular Risk

Adjunctive Agent





high risk

PPI or misoprostol

NSAID; consider use of COX-2 selective agent

low risk

PPI or misoprostol

aspirin and NSAID




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