NSAIDs and Upper GI Bleed

Author: Michelle Lin, MD
Updated: 7/15/2011

NSAIDs and Upper GI Bleed

  • Stomach and platelets have much more COX-1 receptors than COX-2 receptors.
  • Below are statistics from a systematic review on NSAIDs and upper GI complications (bleeding, perforation)

Ketorolac

  • Has the highest relative risk for upper GI complication = 14.54 (see below)
  • Before giving, first check that patients do NOT have a history of a GI bleed or peptic ulcer disease.

NSAID-Induced Complications

NSAID Medication Estimated Relative Risk of Complication [95 % CI]
COX-1 Inhibitors (all) 4.5 [3.82-5.31]
- Ibuprofen 2.69 [2.17-3.33]
- Diclofenac 3.98 [3.36-4.72]
- Meloxicam 4.15 [2.59-6.64]
- Indomethacin 5.40 [4.16-7.00]
- Ketoprofen 5.57 [3.94-7.87]
- Naproxen 5.63 [3.83-8.28]
- Piroxicam 9.94 [5.99-16.50]
- Ketorolac 14.54 [5.87-36.04]
COX-2 Inhibitors (all) 1.88 [0.96-3.71]
- Celecoxib 1.42 [0.85-2.37]
- Aceclofenac 1.44 [0.65-3.2]
- Rofecoxib 2.12 [1.59-2.84]

Risk Factors for Upper GI Complication

  1. Longer drug half-life
  2. Slow-release formulation
  3. Dual inhibition of COX-1 and COX-2 isoenzymes

Relative risk is greatest when first starting medication (<30 days)

References

  • Massó González EL, Patrignani P, Tacconelli S, García Rodríguez LA. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010 Jun;62(6):1592-601 [PubMed]