Primary prevention

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution, especially in people aged over 60 years and those who are taking corticosteroids, bisphosphonates, or other antithrombotic drugs.[24][25]​ Concurrent use of a proton-pump inhibitor (PPI) has been shown to reduce the risk of gastrointestinal complications in patients taking long-term aspirin and/or oral anticoagulants.[36][37][38]

PPIs prevent peptic ulcers and complications in people who require NSAID therapy.[39] However, guidelines suggest considering a test and treat strategy for Helicobacter pylori before starting long-term NSAID therapy, as H pylori eradication has been shown to protect against aspirin-associated peptic ulcer bleeding.[40][41]

Prophylactic use of a PPI is appropriate for patients in intensive care, especially those who require mechanical ventilation, those who are deemed at high risk of gastrointestinal bleeding due to comorbidities such as chronic liver disease, or those who have co-existing conditions such as coagulopathy, sepsis, or acute kidney injury.[33][34]​​ PPIs are generally accepted to be superior to H2 antagonists at preventing clinically important gastrointestinal bleeding in critically ill patients.[34][42][43]​​ Evidence from one double-blind randomised trial suggests that PPIs and H2 antagonists have similar efficacy in reducing the risk of upper gastrointestinal bleeding or ulcers in people taking low-dose aspirin.[44]​ A meta-analysis that evaluated H2 antagonists, PPIs, and prostaglandin analogues found that PPIs were more effective in preventing bleeding from ulcers than H2 antagonists and prostaglandin analogues.[45] PPIs were also more effective in healing ulcers and preventing recurrent bleeding and the need for blood transfusion.[45]

Secondary prevention

Discuss the potential harm associated with non-steroidal anti-inflammatory drugs (NSAIDs) with patients who continue to take them after a peptic ulcer has healed.[46]

  • Review the need for NSAID use regularly (at least every 6 months).

  • Offer a trial of NSAID use on a limited 'as needed' basis.[46]

  • Consider:[46]

    • Reducing the NSAID dose

    • Substituting the NSAID with paracetamol

    • Using an alternative analgesic

    • Using low-dose ibuprofen.

In people at high risk (previous ulceration) and for whom NSAID continuation is necessary, consider a cyclo-oxygenase-2 (COX-2) inhibitor instead of a standard NSAID. In either case, prescribe with a proton-pump inhibitor (PPI).[46]

While avoidance of NSAIDs and cigarette smoking may decrease the risk of recurrence, the role of alcohol intake is less certain. Nonetheless avoidance of excessive alcohol intake is usually recommended.

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