Table 1 Summary of the consistent effects of various risk factors and ulcer prevention strategies with NSAIDs

Risk factors

Age

RCTs show incidence of ulcers to increase with age, more than threefold over five decades

Patients over 75 years old, 2.5-fold increased risk of upper gastrointestinal complications

History of previous ulcer or bleeding

Previous history increases risk of ulcer fourfold in RCTs

Previous history increases risk of bleeding fivefold in RCTs; observational studies support this

Helicobacter pylori

Meta-analysis of RCTs shows 60% decrease in ulcers

Meta-analysis of RCTs shows 80% decrease in ulcers

Aspirin alone

Dose-related increase in ulcers over range of 81 to 325 mg daily

Low-dose aspirin is associated with increased risk of bleeding events

Aspirin plus coxibs or NSAIDs

Low-dose aspirin increases ulcer rates with placebo, coxib, and NSAID in RCTs

Low-dose aspirin increases bleeding rates when added to coxibs or NSAIDs

Ulcer prevention strategies used with NSAIDs

Misoprostol

Misoprostol reduced ulcers by 70% in a meta-analysis of RCTs

Misoprostol reduced bleeds by 40% in a meta-analysis of RCTs

Histamine-2 receptor antagonists

Histamine-2 receptor antagonist therapy reduced ulcers by 60% in a meta-analysis of RCTs

Histamine-2 receptor antagonist therapy reduced bleeds by 30 to 40% in two observational studies

Proton pump inhibitors

Proton pump inhibitor therapy reduced ulcers by 60% in a meta-analysis of RCTs

Observational studies support reduced risk of upper gastrointestinal complications and bleeding with proton pump inhibitor

Coxib use

Pooled analysis across RCTs indicates that coxibs reduce ulcers by about 70% compared with NSAIDs

Pooled analysis across RCTs indicates about a 40 to 50% reduction in ulcer complications with coxibs; observational studies show a consistent 50% reduction or more in upper gastrointestinal bleeding events