Ibuprofen和 COX-2一樣benign? for GI bleeding, 但這是nonrandomized observational study

Comparing Gastrointestinal Risks of Various Drugs

Certain nonsteroidal anti-inflammatory drugs, namely cyclooxygenase-2 inhibitors and ibuprofen, conferred lower risks than others in the class.

Patients at high risk for gastrointestinal (GI) bleeding sometimes have compelling indications for nonsteroidal anti-inflammatory drugs (NSAIDs). To determine which NSAIDs confer the most GI risk, researchers performed a meta-analysis of nine studies (2 cohort and 7 case-control), published between 2000 and 2008.

The overall relative risk for upper GI bleeding or perforation was 4.5 for NSAID users compared with nonusers. Drugs associated with the lowest risks were the selective cyclooxygenase (COX)-2 inhibitors (celecoxib [Celebrex; relative risk, 1.4] and rofecoxib [Vioxx; RR, 2.1]) and ibuprofen (RR, 2.7). Drugs associated with roughly average risks included diclofenac (RR, 4.0), meloxicam (RR, 4.2), indomethacin (RR, 5.4), naproxen (RR, 5.6), and ketoprofen (RR, 5.6). Drugs associated with the highest risks were piroxicam (RR, 9.9) and ketorolac (RR, 14.5). In general, NSAIDs with long plasma half-lives and slow-release formulations conferred higher relative risks than did those with short half-lives. High doses conferred greater risk than low doses.

Comment: Unfortunately, nonrandomized observational studies supply most of the comparative data on GI toxicity of NSAIDs. Recognizing this limitation, we nevertheless might use the findings of this meta-analysis to enlighten our decisions. COX-2 inhibitors confer the lowest GI risk but are associated with elevated cardiovascular risk. The low GI risk associated with ibuprofen is encouraging but might reflect the low doses that often are used. Piroxicam and ketorolac probably should be avoided in high-risk patients. Finally, proton-pump inhibitors can be used concurrently to lower the incidence of NSAID-induced GI ulceration.

— Allan S. Brett, MD

Published in Journal Watch General Medicine June 10, 2010
Citation(s):

González ELM et al. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum 2010 Jun; 62:1592. (http://dx.doi.org/10.1002/art.27412)

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