NSAID Gastropathy

How NSAIDs damage the stomach

NSAIDs block cyclooxygenase (COX) enzymes, reducing prostaglandins that cause pain and inflammation. But prostaglandins also protect the stomach by:

• stimulating protective mucus and bicarbonate
• maintaining blood flow to the lining
• helping the lining repair itself

With less prostaglandin, stomach acid damages the lining more easily. NSAIDs also irritate the lining directly. Damage can occur with tablets, injections, suppositories and even low-dose aspirin taken for the heart. Topical NSAID gels carry very little risk.

Types of damage

Up to about 1 in 4 long-term NSAID users develop an ulcer, and 2 to 4 in 100 have a bleed or perforation each year. Because NSAIDs also reduce pain, ulcers may be "silent" until they bleed.

Risk factors

• age over 65
• previous ulcer or GI bleeding (the strongest risk factor)
• high doses, multiple NSAIDs, or combining an NSAID with aspirin
• blood thinners (warfarin, apixaban, rivaroxaban, clopidogrel)
• corticosteroids
• SSRI antidepressants
• Helicobacter pylori infection
• serious illness such as heart failure, kidney disease or liver disease
• heavy alcohol use and smoking

Some NSAIDs are more damaging than others. Ketorolac and piroxicam carry the highest risk. Ibuprofen at low doses carries a lower risk. COX-2 selective NSAIDs such as celecoxib cause fewer stomach ulcers, but have their own heart risks.

Symptoms

• indigestion or burning upper belly pain
• nausea, bloating and feeling full quickly
• loss of appetite
• signs of bleeding: black, tarry stools, vomiting blood, dizziness
• signs of slow blood loss: tiredness, breathlessness, pale skin, iron deficiency anemia

Diagnosis

• Upper endoscopy: the main test, showing erosions, ulcers and bleeding, and allowing biopsies and treatment
• H. pylori testing: breath, stool or biopsy test
• Blood count and iron studies to check for anemia
• Capsule endoscopy if small bowel damage is suspected

Treatment

• Stop the NSAID if possible, or switch to a lower-risk option.
• Proton pump inhibitors (PPIs): heal ulcers within about 8 weeks, and help even if the NSAID must continue.
• Treat H. pylori if present, which reduces ulcer risk.
• Endoscopic treatment for bleeding ulcers: clips, heat or injections.
• Blood transfusion and iron for blood loss.
• Surgery for perforation.

Prevention

If you need an NSAID:

• use the lowest effective dose for the shortest time
• take it with food
• avoid combining NSAIDs, including over-the-counter products that contain ibuprofen or aspirin
• consider acetaminophen (paracetamol) or topical NSAID gels first for joint and muscle pain
• ask about PPI protection if you are over 65, have had an ulcer, take blood thinners, steroids or SSRIs, or need long-term NSAIDs
• test and treat H. pylori before starting long-term NSAIDs if you are at higher risk
• people with a previous bleeding ulcer may be advised to avoid NSAIDs altogether, or to use celecoxib with a PPI under medical supervision
• do not stop low-dose aspirin prescribed for heart protection without talking to your doctor

Frequently asked questions

What is NSAID gastropathy?

It is damage to the stomach and duodenum lining caused by NSAIDs such as ibuprofen, naproxen and aspirin. It ranges from small erosions to ulcers that can bleed or perforate. It is one of the most common causes of peptic ulcers.

Can ibuprofen cause stomach bleeding?

Yes. Ibuprofen and other NSAIDs can cause ulcers that bleed, sometimes without any warning pain. The risk is higher with high doses, long-term use, older age, previous ulcers, and use with blood thinners or steroids.

How do I protect my stomach while taking NSAIDs?

Use the lowest dose for the shortest time, take it with food, avoid combining NSAIDs, and ask your doctor about a proton pump inhibitor if you are at higher risk. Topical NSAID gels or acetaminophen are safer alternatives for many people.

What are the warning signs of an NSAID ulcer?

Watch for burning upper belly pain, indigestion, nausea, black or tarry stools, vomiting blood or coffee-ground material, dizziness and unexplained tiredness. Bleeding can occur without previous pain, so black stools always need urgent assessment.

Does low-dose aspirin damage the stomach?

It can. Even low-dose aspirin taken for heart protection increases the risk of ulcers and bleeding, especially with other NSAIDs, blood thinners or a past ulcer. Your doctor may add a stomach-protecting medicine rather than stop aspirin.