Primary prevention

Aspirin and other nonsteroidal 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 (GI) complications in patients taking long-term aspirin therapy and/or oral anticoagulants.[35][36][37]​​​​​

PPIs prevent peptic ulcers and complications in people who require NSAID therapy.[38] However, guidelines suggest considering a test and treat strategy for Helicobacter pyloribefore starting long-term NSAID therapy, as H pylori eradication has been shown to protect against aspirin-associated peptic ulcer bleeding.[33][39]

PPI therapy may be more effective than misoprostol (a prostaglandin E1 analog) for the prevention of GI ulcers in people prescribed long-term NSAID therapy. [ Cochrane Clinical Answers logo ] ​ Compliance with misoprostol (particularly at high doses) may be compromised by GI adverse effects, including abdominal cramping and diarrhea.

Prophylactic use of a PPI is appropriate for patients in intensive care, who are deemed at high risk of GI bleeding due comorbidities such as chronic liver disease, or have coexisting conditions such as coagulopathy, shock, or liver disease.[34]​​[40]​ Mechanical ventilation by itself is no longer considered a risk factor.[34][41]​​​​ All critically ill adults with factors that likely increase the risk for stress-related upper GI bleeding should receive either a PPI or a H2 antagonists to prevent bleeding.[42][34]​​​​ Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness.[34]​ Discontinuation of stress ulcer prophylaxis before transfer out of the intensive care unit is necessary to prevent inappropriate prescribing.[43]

Evidence from one double-blind randomized trial suggests that PPIs and H2 antagonists have similar efficacy in reducing the risk of upper GI or ulcers in people taking low-dose aspirin.[44]​ A meta-analysis that evaluated H2 antagonists, PPIs, and prostaglandin analogs found that PPIs were more effective in preventing bleeding from ulcers than H2 antagonists and prostaglandin analogs.[45] PPIs were also more effective in healing ulcers and preventing recurrent bleeding and the need for blood transfusion.[45]

Secondary prevention

While avoidance of nonsteroidal anti-inflammatory drugs (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. Guidance from the American Gastroenterological Association supports the long-term use of proton-pump inhibitors (>8 weeks) for the secondary prevention of peptic ulcers in patients taking aspirin or other NSAIDs at high risk for upper gastrointestinal bleeding (e.g., older than 60 years of age, severe medical comorbidity, using a second NSAID, taking an antithrombotic drug, or taking an oral corticosteroid).[85]

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