Cimetidine decreases aspirin-induced gastric mucosal damage in humans

The role of H2-receptor antagonists in the prevention of NSAID-induced gastrointestinal damage

Non-steroidal anti-inflammatory drugs (NSAIDs) induce gastric and duodenal damage in animals and humans. The possible protection afforded by cimetidine against acute and short-term NSAID-induced mucosal damage was evaluated in five studies. Cimetidine 200 mg once daily and 400 mg once daily was found to protect the gastric mucosa against damage induced by a single dose of aspirin 1300 mg; this protection was found to be independent of gastric acid secretion. Cimetidine 200 mg q.d.s. was found to protect the stomach and duodenum against damage induced by 14 days' treatment with aspirin 650 mg q.d.s. Duodenal and gastric damage induced during a 7-day treatment period with naproxen 500 mg b.d. was prevented by cimetidine 400 mg b.d.; this dose of cimetidine also provided significant duodenal protection against damage induced by 1 week of therapy with indomethacin 50 mg t.d.s. There is no correlation between upper gastrointestinal symptoms, or between mucosal prostanoids, and the presence or absence of mucosal damage. Cimetidine is therefore effective in the prevention of mucosal damage induced by short-term treatment with NSAIDs.

Cimetidine reduces bile acid-mediated small intestinal mucosal injury in rats in vivo

Whether cimetidine has protective effects on the gastrointestinal mucosa independent of its ability to reduce gastric acid secretion is still controversial. To study this, rats had small intestinal mucosal injury induced in vivo by perfusion with 5 mM chenodeoxycholic acid. Control rats were compared to rats receiving either intraperitoneal or intravenous pretreatment with 50 mg/kg cimetidine or intraluminal pretreatment with 0.5 mM cimetidine. Mucosal injury was assessed by measuring villus tip epithelial cell denudation by computerized quantitative morphology. Intraperitoneal cimetidine reduced the average denudation/villus (micrometers) caused by 45-min perfusion with chenodeoxycholic acid: control = 39.1 +/- 7.7 (SEM), intraperitoneal cimetidine = 20.8 +/- 3.5 (P less than 0.05). Additionally, both intraluminal and intravenous cimetidine reduced villus denudation caused from 30 min perfusion with chenodeoxycholic acid: control = 62.5 +/- 5.8, intravenous cimetidine = 42.6 +/- 4.7 (P less than 0.05), intraluminal cimetidine = 44.6 +/- 7.2 (P less than 0.05). The observation that reduced mucosal injury is observed in an in vivo model that is independent of gastric acid supports the conclusion that cimetidine indeed has acid-independent protective properties.

Non-steroidal anti-inflammatory drugs in patients with peptic ulcer disease: to be considered in certain circumstances

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Prevention of gastroduodenal damage induced by non-steroidal anti-inflammatory drugs: controlled trial of ranitidine

OBJECTIVE

To evaluate the prophylactic effect of ranitidine 150 mg twice daily in patients requiring one of the following non-steroidal anti-inflammatory drugs: naproxen, piroxicam, diclofenac, and indomethacin. In addition, risk factors were studied in order to help in targeting of such treatment to specific groups of patients.

DESIGN

Double blind, placebo controlled, randomised, parallel group with endoscopic assessments at 0, 4, and 8 weeks.

SETTING

Multicentre outpatient study at secondary referral centres in five European countries. PATIENTS--297 patients with rheumatoid arthritis or osteoarthritis over the age of 18 without lesions in the stomach and duodenum at baseline endoscopy (after one week without taking non-steroidal anti-inflammatory drugs). Those taking other antirheumatic agents, concomitant ulcerogenic drugs, or treatment for peptic ulcers within the previous 30 days were excluded. Age, sex, arthritic disease, and type of non-steroidal anti-inflammatory drug used were comparable in the two treatment groups. In all, 263 patients completed the trial.

INTERVENTIONS

Ranitidine 150 mg twice daily or placebo (plus the selected non-steroidal anti-inflammatory drug) was prescribed within five days after the baseline endoscopy for two consecutive periods of four weeks. Paracetamol was permitted during the study, but not antacids. Patients were withdrawn if the most severe grade of damage (including ulceration) was found at the four week endoscopy or when indicated, or with lesser damage at the investigator's discretion.

END POINT

Frequency of gastric and duodenal ulceration or lesions, or both.

MEASUREMENTS AND MAIN RESULTS

The cumulative incidence of peptic ulceration by eight weeks was 10.3% (27/263); 2 out of 135 (1.5%) developed duodenal ulceration in the ranitidine group, compared with 10 out of 126 (8%) taking placebo. The frequency of gastric ulceration was the same (6%) for the two groups at eight weeks. Though significantly fewer gastric lesions developed in the ranitidine group by eight weeks. The frequency of non-ulcerative lesions in the duodenum did not differ greatly for the two groups at either time point. Twelve out of 75 (16%) patients taking piroxicam developed peptic ulceration, of whom two thirds had duodenal ulceration. Patients with a history of peptic ulcer were particularly susceptible to recurrent ulceration, against which ranitidine offered some protection.

CONCLUSIONS

Ranitidine 150 mg twice daily significantly reduced the incidence of duodenal ulceration but not gastric ulceration when prescribed concomitantly with one of four commonly used non-steroidal anti-inflammatory drugs.

Review: acute human models of gastric mucosal injury

The use of acute human models of gastric mucosal injury has been stimulated by a need to understand more fully the problems of non-steroidal anti-inflammatory drugs but such models have other applications. None is ideal and they all share certain drawbacks. For none of them has a precise relationship to clinical events been established and they have all tended to be employed on a population of young healthy subjects who are not those at greatest clinical risk. Of individual methods mucosal potential difference is an indirect measure which is too often affected by other influences to be acceptable as a measure of mucosal injury when used alone, although it has some value as an adjunct to other measurements. Assay of DNA in gastric washings is a suitable technique for quantifying desquamation of gastric epithelial cells occurring in response to acute injury; on present evidence its significance is much more difficult to assess in the context of continuing challenge over several days. By contrast, measurement of microbleeding is more suitable for quantifying injury over several days of NSAID ingestion; little bleeding is recorded with a single acute challenge. Endoscopy can demonstrate macroscopic lesions which result from mucosal injury--injury which is quantified more easily and sensitively by measurements of cellular exfoliation or bleeding. Paradoxically, endoscopy's strength has been to underline the scientific weakness of acute models because it shows that it is rare for ulcers, which are the lesions of clinical concern to develop in these studies.