An endoscopic evaluation of the effects of non-steroidal anti-inflammatory drugs on the gastric mucosa

Combination therapy with ibuprofen and methadone for chronic cancer pain

This randomized double-blind crossover study compares the narcotic methadone alone with methadone in combination with the peripherally acting, antiprostaglandin agent ibuprofen (Motrin, Upjohn) in 28 patients with moderate to severe cancer-related pain, who were already using a narcotic for pain relief. Results show that the addition of 600 mg of ibuprofen to either 2.5 or 5 mg of methadone significantly increased analgesia, without concomitantly increasing side effects or euphoria.

Endoscopic studies of gastric and duodenal injury after the use of ibuprofen, aspirin, and other nonsteroidal anti-inflammatory agents

The toxic effects of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) were endoscopically evaluated in several studies conducted between 1975 and 1983 and involving 843 normal volunteers. Anti-inflammatory doses of acetylsalicylic acid (2,400 and 3,900 mg/day) consistently produced significantly more mucosal injury than did any of the newer NSAIDs. Buffering did not reduce the degree of damage. Little or no mucosal injury was seen with placebo, "pro drugs," enteric-coated aspirin, or 1,200 mg/day of ibuprofen (Motrin, Upjohn). However, varying degrees of generally dose-dependent mucosal injury were evident with larger doses of ibuprofen, naproxen, tolmetin sodium, and indomethacin. The amount of mucosal damage after 2,400 mg/day of ibuprofen did not increase when 4,800 mg daily was administered. Duodenal injury corresponded to gastric injury, but it was generally less severe. Short-term studies of one to three days indicated that ibuprofen produced little or no injury when given at a dose of 2,400 mg for one day or 1,600 mg/day for three days. No relation was noted between subjective symptoms and endoscopic findings.

A controlled endoscopic study comparing the toxic effects of sulindac, naproxen, aspirin, and placebo on the gastric mucosa of health volunteers

Sixty volunteers were endoscopically evaluated to compare gastric mucosal injury following oral administration of sulindac, naproxen, aspirin, or placebo for two consecutive seven-day periods. A single-blind technique was utilized wherein the endoscopist was unaware which drug each volunteer had received. The following dosages were employed for the two study periods: sulindac, 150 and 200 mg, b.i.d., naproxen, 250 and 375 mg, b.i.d., and aspirin, 650 and 975 mg, q.i.d. The only subject who developed a frank ulcer with mucosal bleeding was in the sulindac group, however volunteers taking sulindac demonstrated statistically less significant mucosal injury on endoscopic examination than those receiving naproxen or aspirin.

The argument for aspirin as the NSAID of choice in the management of rheumatoid arthritis

In view of their costliness, the use of newer NSAIDs is justified if they are demonstrably more effective, less toxic, or better tolerated than aspirin (ASA). However, there is no evidence that any is more effective than ASA, and their widely assumed comparable effectiveness has not been demonstrated convincingly. In terms of clinically meaningful overt and even occult gastrointestinal blood loss, ASA is indistinguishable from the newer NSAIDs. Most NSAIDs evoke fewer unpleasant gastrointestinal symptoms than ASA does, although current recording of such symptoms has magnified the ASA experience. Prescribing a new NSAID before ASA requires a heuristic assertion of comparable effectiveness, misconception of overt toxicities, and belief in the meaningfulness of data demonstrating differential tolerance. The trade-off is increased expense and unknown long-term toxicity.

Effects of fenbufen, indomethacin, naproxen, and placebo on gastric mucosa of normal volunteers. A comparative endoscopic and photographic evaluation

The effects of fenbufen (1,000 mg a day), indomethacin (150 mg a day), naproxen (750 mg a day), and placebo on gastric mucosa were determined by endoscopy and recorded photographically. One hundred normal subjects, randomly divided into equal, parallel-treatment groups, were given the drugs in divided daily doses for seven consecutive days. The results revealed that the effects of fenbufen on gastric mucosa were significantly (p less than or equal to 0.05) less than those of either naproxen or indomethacin and not statistically different from those observed with placebo.

An analysis of the gastro-intestinal side-effects of non-steroidal anti-inflammatory drugs, with particular reference to comparative studies in man and laboratory species

A critical analysis has been performed of reports published on the incidence of gastro-intestinal (GI) side-effects found in arthritic patients being treated with non-steroid anti-inflammatory (NSAI) drugs. The results show the following: 1. The incidence of GI ulceration (as revealed by gastroscopy) and haemorrhage in arthritic patients taking NSAI drugs may be higher than suspected from clinical trial data. 2. Incidence of all GI side-effects (including ulceration and haemorrhage) may be lower with some of the new NSAI drugs than with traditional drugs (e.g. aspirin, indomethacin and phenylbutazone). 3. Arthritic patients may be more susceptible to the ulcerogenic actions of NSAI drugs. Experiments with animals, together with evidence from clinical studies, indicate that stress factors and the presence of decreased mucosal resistance in the diseased state may contribute to the enhanced susceptibility of the GI tract towards the ulcerogenicity of NSAI drugs. 4. Comparison of data on gastroscopic observations in man with the author's data on the effects of NSAI drugs in stress-sensitized rats shows the latter technique appears to be a useful means of predicting the ulcerogenic potential of NSAI drugs in man. The comparison has also been used to predict the ulcerogenicity of drug - alcohol combinations; alcohol being a common ulcerogen consumed by many patients. Some NSAI drugs with low ulcerogenic activity (i.e. azapropazone, benoxaprofen and fenclofenac) in the stressed-rat assay show little or no interaction with alcohol. These studies using laboratory animals show the importance of employing conditions to mimic environmental factors (e.g. stress and alcohol consumption) which might predispose individuals to ulcerogenic or other side-effects of NSAI drugs. From these studies it appears possible to construct 'predictive profiles' of the relative ulcerogenicity of NSAI drugs which may be applicable to the clinical situation in man.

Gastroscopic observations following aspirin and naproxen sodium administration

A double-blind crossover study was conducted to compare the effects of aspirin (3.25 Gm/day) and a new nonsteroidal antiinflammatory drug, naproxen sodium (1.1 Gm/day), on the gastric mucosa of 12 healthy volunteers. Subjects were gastroscoped after one week on each drug, intragastric photographs were obtained, and gastric contents were examined for blood. Ten subjects exhibited some degree of gastric pathology following aspirin administration, compared with one subject with gastric pathology following naproxen sodium. Naproxen sodium also induced less gastrointestinal bleeding and caused fewer side effects than aspirin.

Gastroscopic evaluation of the effect of aspirin and oxaprozin on the gastric mucosa

Oxaprozin, a new long-acting, antiinflammatory agent, and aspirin were compared utilizing gastroscopic evaluation and photography of the gastric mucosa in a double-blind, crossover study in normal volunteers. Submucosal hemorrhages or mucosal bleeding was observed in seven of eight subjects on aspirin and in only two of eight on oxaprozin (P = 0.061). Adverse effects were experienced by seven of eight subjects after the aspirin treatment period--tinnitus in five and gastrointestinal symptoms in four. Only one patient had mild diarrhea on oxaprozin. The incidence of adverse effects was found significantly higher with aspirin therapy (P less than 0.001). No laboratory abnormalities of clinical significance were attributed to either drug administration. Results after ten days of treatment show that oxaprozin in therapeutic dose levels (1200 mg once a day) produces significantly fewer changes in the gastric mucosa than aspirin (975 mg administered four times a day, total daily dose 3.9 Gm) in the same subjects, who received both drugs in this double-blind, crossover experiment with a four-week washout period between treatments.

Endoscopic evaluation of gastric tolerance to fenclofenac

Gastrointestinal irritation is a common consequence of treatment with many non-steroidal anti-inflammatory agents. An open tolerance study with endoscopic control employing fenclofenac in doses of 900 or 1200 mg daily in ten patients with osteoarthrosis, was carried out over an eight week period. The principal aim of the study was to evaluate the effect of fenclofenac on the gastroduodenal mucosa in a selected group of patients with osteoarthrosis and with a history of gastric intolerance to other non-steroidal anti-inflammatory agents. All patients tolerated fenclofenac well and showed clinical improvement.

Cimetidine for peptic ulcer in patients with arthritis

Patients taking anti-inflammatory drugs for arthritis are prone to dyspepsia, and management of peptic ulcer is difficult because surgery is poorly tolerated. In this open study cimetidine treatment was associated with ulcer healing in 17 out of 21 patients with arthritis even when anti-inflammatory treatment was continued. Remission was maintained for 1 year by continued cimetidine therapy.

Gastrointestinal toxicity of minor analgesics

1 The evidence for the risk of gastric erosions from aspirin is fragmentary. 2 Occult gastric bleeding following aspirin is poorly studied and the skewed distribution is unexplained; platelet factors may be relevant. 3 Overt gastric bleeding may follow aspirin; the risk is probably about one episode per two million doses. 4 There is epidemiological, clinical, experimental and histopathological evidence for an association between chronic aspirin use and chronic gastric ulcer. 5 An alternative to the Davenport hypothesis is proposed to explain the gastric action of aspirin and the non-steroidal anti-inflammatory agents. 6 Paracetamol is probably bland in its gastric actions.

The effects of ibuprofen, indomethacin, aspirin, naproxen, and placebo on the gastric mucosa of normal volunteers: a gastroscopic and photographic study

The effects of various nonsteroidal antiinflammatory drugs on the gastric mucosa were endoscopically evaluated in 40 normal volunteers. Eight groups, each containing five subjects were designed: aspirin (3600 mg/d); placebo; ibuprofen (1600 mg/d); ibuprofen (2400 mg/d); indomethacin (100 mg/d); indomethacin (150 mg/d); naproxen (500 mg/d); and naproxen (750 mg/d). All volunteers took medication for seven days and gastroscopy was carried out on day one and day eight. All findings were documented by photography. Severe gastric mucosal injury occurred with aspirin (P less than 0.05), both doses of indomethacin, and the higher dose of naproxen. Lesser changes were seen with the lower dose of naproxen, both doses of ibuprofen and placebo. The higher doses of ibuprofen, indomethacin, and naproxen caused a greater degree of gastric mucosal injury, but statistical significance was achieved only with naproxen (P less than 0.01). Subjective gastrointestinal complaints generally correlated with endoscopic pathology; however, nine volunteers had evidence of severe injury to the gastric mucosa with no symptomatology. This was confined to the patients on indomethacin, naproxen, and ibuprofen. Aspirin patients all had some degree of symptomatology but to a lesser degree than expected in view of the endoscopic findings.

A review of upper-gastrointestinal effects of the newer nonsteroidal antiinflammatory agents

Newer nonsteroidal antiinflammatory agents (NSAI's) such as ibuprofen, neproxen, fenoprofen, and tolmetin have broadened the therapeutic choice and increased the chances of providing optimum arthritis control, but require careful assessment of the possibilities for unwanted drug effects when long-term therapy is required. A review of the literature on the gastrointestinal effects of the promising newer NSAIs, as compared with the older agents, aspirin, indomethacin, and phenylbutazone, is presented, highlighting animal toxicology and human adverse reaction surveillance data and the evidence for various suggested pathophysiological mechanisms.

Gastric mucosal damage caused by plain and microencapsulated acetylsalicylic acid tablets in healthy subjects: a gastrocamera study

In a randomized, cross-over study plain acetylsalicylic acid (ASA) tablet and microencapsulated ASA tablets were given in doses of 1 gram 3 times a day for 3 days to 8 healthy subjects with no previous gastrointestinal disturbances. Gastrocamera examinations were performed before the ASA treatment and 1--2 hours after the last dose of ASA. The gastric mucosa appeared macroscopically normal at all the control examinations; whereas musocal bleeding was evident in all the subjects after the ASA treatment. There was no statistically significant difference between the plain ASA and the microencapsulated ASA preparations. No correlation could be found between the ASA concentration in plasma and the gastric mucosal damage.

Endoscopic study of gastro-intestinal injury with non-steroidal anti-inflammatory drugs

A double-blind placebo controlled study was carried out in 24 healthy male volunteers to assess the nature and extent of any gastro-intestinal damage caused by the short-term administration of flurbiprofen (300 mg/day), aspirin (2.1 g/day), and phenylbutazone (600 mg/day). Fibre-optic endoscopic examinations were made before and after 7-days' treatment by 3 observers. The results showed that aspirin produced severe and extensive damage. The changes seen with phenylbutazone were less severe than with aspirin but more marked than with flurbiprofen. Flurbiprofen was found to have produced minor changes which tended to be localized. The histopathological findings correlated well with the endoscopic observations.

Acute gastric mucosal injury during continuous or interrupted aspirin ingestion in humans

The effect of continuous versus interrupted high-dose aspirin (ASA) for 14 days was evaluated in a randomized double-blind study in 8 rheumatoid arthritis patients. Acute gastric mucosal injury was measured by serial gastroscopy and gastric biopsy. Significant gross mucosal damage was seen in all patients following 3 days of ASA (P less than 0.01) and persisted without significant change in severity to the end of the study. Histologic gastritis in areas free of hemorrhages and erosions was not increased significantly by ASA. In spite of gross mucosal injury, symptoms occurred infrequently. Serum pepsinogen I, but not serum gastrin, increased significantly following 3 days of ASA, and the elevation persisted to the end of the study. The extent of mucosal injury at 14 days was not significantly different in those receiving ASA continuously from those on an interrupted schedule. Thus, gastric mucosal adaptation to ASA in man was not demonstrated.

Antiinflammatory drugs and gastrointestinal bleeding: a comparison of aspirin and ibuprofen

Gastrointestinal blood loss provoked by short-term and long-term therapy with aspirin and ibuprofen was compared in patients with rheumatoid arthritis. Blood loss was assessed by isotope counting of four-day stool collections after infusion of 51Cr-labeled autologous erythrocytes. After two weeks on drug or after one year on drug, aspirin consistently caused more bleeding than ibuprofen.

Serum pyridoxal in patients with rheumatoid arthritis

Abnormalities of tryptophan metabolism have been reported in patients with rheumatoid arthritis (RA) and it has been suggested that these abnormalities are the result of disordered vitamin B6 metabolism. Fasting serum pyridoxal, assayed by an automated microbiological system, was found to be below normal in 35 out of 42 patients with RA while a similar abnormality was found in 8 out of 35 patients with osteoarthrosis (OA). Within the RA group the abnormality could not be related to the age, sex, or drug therapy of individuals but of the 8 patients with OA and a low serum pyridoxal, 7 were receiving indomethacin either alone or in conjunction with aspirin.