misoprostol and Dyspepsia

Gastrointestinal toxicity is a common adverse effect of traditional non-steroidal anti-inflammatory drugs (NSAIDs) and patients at risk should receive prevention therapies. Selective cyclooxygenase-2 (COX-2) inhibitors (coxibs) are safer to the gastrointestinal tract than traditional NSAIDs. Current prevention strategies in patients who need NSAIDs should also take into account the presence of cardiovascular risk factors, as coxibs and probably most traditional NSAIDs increase the incidence of serious cardiovascular events. Patients without risk factors should be treated with traditional NSAIDs, whereas patients at risk may receive cotherapy with a proton pump inhibitor (PPI) or misoprostol, or a coxib alone. However, patients with a previous bleeding ulcer should receive the combination of a coxib plus a PPI, and Helicobacter pylori should be tested for and treated if present. Coxib and NSAID therapy should be prescribed with caution in patients with increased cardiovascular risk and should be prescribed at the lowest possible dose and for the shortest period of time. These patients will probably be treated with low-dose aspirin or other antiplatelet agents, which puts them at increased risk of upper gastrointestinal complications. The risk of gastrointestinal toxicity with combined therapy of aspirin and coxib may be lower than that with traditional NSAIDs plus aspirin, but all these patients may benefit from PPI cotherapy. When the lower gastrointestinal tract is of concern, coxib instead of NSAID therapy should be considered. Coxib therapy has better gastrointestinal tolerance than traditional NSAIDs and PPI therapy is effective both in the treatment and prevention of NSAID-induced dyspepsia and should be considered in patients who develop dyspepsia during NSAID or coxib therapy.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Cyclooxygenase 2 Inhibitors; Drug Combinations; Dyspepsia; Evidence-Based Medicine; Gastrointestinal Diseases; Gastrointestinal Hemorrhage; Helicobacter Infections; Helicobacter pylori; Humans; Middle Aged; Misoprostol; Proton Pump Inhibitors

Gastric and duodenal injury related to nonsteroidal anti-inflammatory drug (NSAID) use is extremely common, and a variety of strategies can be employed to reduce this frequent side effect of an otherwise useful category of medications. Although the best approach may be to discontinue NSAID treatment, this is not always possible for patients with arthritis pain or for those who require low-dose aspirin therapy for underlying cardiovascular disease. In arthritis cases, one of the new cyclooxygenase-2 specific inhibitors can be used to replace a traditional NSAID, but the addition of another drug to treat and heal ulcers is normally still needed. Patients taking aspirin are also candidates for additional treatment.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Aspirin; Dyspepsia; Histamine H2 Antagonists; Humans; Misoprostol; Peptic Ulcer; Ranitidine

NSAID-associated dyspeptic symptoms are common and can be managed empirically with an H2-receptor antagonist or a proton-pump inhibitor. Treatment of established gastroduodenal ulcers is accomplished best by withholding the offending drugs. Proton-pump inhibitors appear to heal ulcers at the same rate whether or not NSAID therapy is continued. After the ulcer is healed and if NSAID therapy must be continued, prophylaxis is accomplished best by the concomitant use of proton-pump inhibitors, misoprostol (at least 200 micrograms 3 times a day), or a NSAID that preferentially inhibits COX-2. The future development of newer, safer NSAID preparations, including highly selective COX-2 inhibitors and nitric oxide-releasing NSAIDs, should provide better treatment options for the increasing number of individuals requiring anti-inflammatory agents.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Cyclooxygenase 2; Cyclooxygenase 2 Inhibitors; Cyclooxygenase Inhibitors; Duodenal Ulcer; Dyspepsia; Enzyme Inhibitors; Histamine H2 Antagonists; Humans; Isoenzymes; Membrane Proteins; Misoprostol; Nitric Oxide Donors; Peroxidases; Prostaglandin-Endoperoxide Synthases; Proton Pump Inhibitors; Stomach Ulcer

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Dyspepsia; Humans; Misoprostol; Omeprazole; Peptic Ulcer; Ranitidine; Wound Healing

To integrate the realization that peptic ulcer most commonly reflects infection with Helicobacter pylori or use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) into a disease management approach.. Guidelines were outlined by the author and presented for review to the American College of Gastroenterology (ACG) Practice Parameters Committee, selected by the president of the ACG, and a panel of experts in peptic ulcer, selected by the committee.. These guidelines were formulated following extensive review of the literature obtained by MEDLINE search and presented for detailed review and revision to unpublicized committee meetings on three occasions and to experts by mail. These recommendations are an official statement of the ACG and have been approved by the American Gastroenterological Association and the American Society for Gastroenterological Endoscopy. Firm recommendations are discriminated from reasonable suppositions pending definitive data.. Since cure of H. pylori infection decreases recurrence rates and facilitates healing, antibiotic therapy is indicated for all H. pylori-infected ulcer patients. No optimal, simple antibiotic regimen has yet emerged. Simultaneous conventional ulcer therapy is recommended to facilitate symptom relief and healing. For refractory ulcers, only maximal acid inhibition offers advantage over continued conventional therapy; cure of H. pylori infection is likely to facilitate healing of refractory ulcers. Only with complicated or refractory ulcers should conventional maintenance therapy be continued, at least until successful H. pylori eradication is confirmed. A search for NSAID use is indicated for all ulcer patients. For NSAID-associated ulcers these drugs should be discontinued if possible and H. pylori, if present, should be cured.

Topics: Antacids; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Biopsy; Bismuth; Breath Tests; Contraindications; Drug Therapy, Combination; Dyspepsia; Helicobacter Infections; Helicobacter pylori; Histamine H2 Antagonists; Humans; Metronidazole; Misoprostol; Peptic Ulcer; Predictive Value of Tests; Proton Pump Inhibitors; Recurrence

Misoprostol is effective for ulcers associated with the use of nonsteroidal antiinflammatory drugs (NSAIDs) but is often poorly tolerated because of diarrhea and abdominal pain. We compared the efficacy of omeprazole and misoprostol in healing and preventing ulcers associated with NSAIDs.. In a double-blind study, we randomly assigned 935 patients who required continuous NSAID therapy and who had ulcers or more than 10 erosions in the stomach or duodenum (or both) to receive 20 mg or 40 mg of omeprazole orally in the morning or 200 microg of misoprostol orally four times daily. Patients were treated for four weeks or, in the absence of healing, eight weeks. Treatment success was defined as the absence of ulcers and the presence of fewer than five erosions at each site and not more than mild dyspepsia. We then randomly reassigned 732 patients in whom treatment was successful to maintenance therapy with 20 mg of omeprazole daily, 200 microg of misoprostol twice daily, or placebo for six months.. At eight weeks, treatment was successful in 76 percent of the patients given 20 mg of omeprazole (233 of 308), 75 percent of those given 40 mg of omeprazole (237 of 315), and 71 percent of those given misoprostol (212 of 298). The rates of gastric-ulcer healing were significantly higher with 20 mg of omeprazole (but not 40 mg of omeprazole) than with misoprostol. Healing rates among patients with duodenal ulcers were higher with either dose of omeprazole than with misoprostol, whereas healing rates among patients with erosions alone were higher with misoprostol. More patients remained in remission during maintenance treatment with omeprazole (61 percent) than with misoprostol (48 percent, P=0.001) and with either drug than with placebo (27 percent, P<0.001). There were more adverse events during the healing phase in the misoprostol group than in the groups given 20 mg and 40 mg of omeprazole (59 percent, 48 percent, and 46 percent, respectively).. The overall rates of successful treatment of ulcers, erosions, and symptoms associated with NSAIDs were similar for the two doses of omeprazole and misoprostol. Maintenance therapy with omeprazole was associated with a lower rate of relapse than misoprostol. Omeprazole was better tolerated than misoprostol.

Topics: Adult; Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Double-Blind Method; Duodenal Ulcer; Dyspepsia; Female; Humans; Male; Middle Aged; Misoprostol; Omeprazole; Prognosis; Proton Pump Inhibitors; Recurrence; Remission Induction; Stomach Ulcer

One hundred and thirty-seven consecutive outpatients with non-ulcer dyspepsia (NUD) and erosive prepyloric changes (EPC) were randomly allocated to double-blind treatment with 400-micrograms misoprostol tablets twice daily or placebo for 4 weeks. Misoprostol had a significant worsening effect on epigastric pain, nausea, meteorism, lower abdominal pain, and diarrhoea, as compared with placebo. The fact that symptoms in patients with NUD and EPC were exacerbated by an antisecretory dose of misoprostol indicates that the symptoms are largely unrelated to gastric acid.

Topics: Adolescent; Adult; Aged; Alprostadil; Anti-Ulcer Agents; Double-Blind Method; Dyspepsia; Female; Gastric Mucosa; Humans; Male; Middle Aged; Misoprostol; Pylorus

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Cyclooxygenase 2 Inhibitors; Dyspepsia; Female; Helicobacter Infections; Helicobacter pylori; Histamine H2 Antagonists; Humans; Ibuprofen; Middle Aged; Misoprostol; Osteoarthritis; Sucralfate

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Cyclooxygenase Inhibitors; Dyspepsia; Histamine H2 Antagonists; Humans; Misoprostol; Omeprazole; Proton Pump Inhibitors; Risk Factors; Stomach Ulcer; Time Factors

Thirteen juvenile chronic arthritis patients with abdominal symptoms related to non-steroidal anti-inflammatory drug therapy were endoscoped before and after a 6-week course of either misoprostol or ranitidine therapy. Major presenting symptoms were generalized abdominal pain and nausea. Symptoms did not correlate well with endoscopic findings which revealed no evidence of ulceration and minimal erosive damage. Five patients had mild erythema or gastritis. Bleeding lesions were confined to small numbers of petechiae. Following treatment with either misoprostol or ranitidine, patients improved symptomatically without a corresponding improvement on endoscopic and histological examination of stomach and duodenum. Both treatments were well tolerated.

Topics: Adolescent; Anti-Inflammatory Agents, Non-Steroidal; Arthritis, Juvenile; Child; Child, Preschool; Duodenum; Dyspepsia; Endoscopy; Female; Gastrointestinal Diseases; Humans; Male; Misoprostol; Ranitidine; Stomach