Misoprostol NSAIDs

In the setting of chronic renal failure in which NSAIDs are being intercurrently used, we conclude that the nephroprotective role of misoprostol has not yet been satisfactorily resolved and additional controlled trial of misoprostol-NSAID effect in patients with more pronounced chronic renal failure could resolve this quandary. 

Misoprostol increases the incidence of abdominal pain and diarrhoea when used with diclofenac or indometacin. Isolated cases of neurological adverse effects have been seen with naproxen or phenylbutazone given with misoprostol. However, no important pharmacokinetic interactions seem to occur between aspirin, diclofenac, ibuprofen or indometacin and misoprostol. NSAIDs are reported not to affect the abortive effects of intravaginal misoprostol. 

In patients at risk for NSAID-induced ulcers, proton pump inhibitors (PPIs) at standard doses reduce the risk of both gastric and duodenal ulcers as effectively as misoprostol and are generally better tolerated. 

Refer to Chapter 14 on gastroesophageal reflux disease for more information on the PPIs. The PPI omeprazole is superior to both ranitidine and misoprostol for preventing recurrence of NSAID-associated PUD. In one study, omeprazole 20 mg daily was compared to misoprostol 200 meg twice daily for NSAID-associated PUD prevention. At 6 months, the omeprazole-treated group had significantly fewer ulcers than those taking misoprostol. Furthermore, more patients discontinued ulcer prophylaxis in the misoprostol group due to adverse events.26... 

For OA patients who need an NSAID but are at high risk for GI complications, the ACR recommendations include either a COX-2 selective inhibitor or a nonselective NSAID in combination with either a proton pump inhibitor or misoprostol. 

NSAID with analgesic properties, and misoprostol, a Gl mucosal protective prostaglandin analog. 

Hypersensitivity to diclofenac or to misoprostol or other prostaglandins. Do not give to patients who have experienced asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. 

Misoprostol should not be used for reducing the risk of NSAID-induced ulcers in women of childbearing potential unless the patient is at high risk of developing complications from gastric ulcers associated with NSAIDs or of developing gastric ulceration. In such patients, misoprostol may be prescribed if the patient ... 

Adults 200 meg 4 times daily with food. If this dose oannot be tolerated, 100 meg may be used. Take misoprostol for the duration of NSAID therapy as presoribed. Take with meals, with the last dose of the day taken at bedtime. 

Duodenal ulcers Misoprostol does not prevent duodenal uleers in patients on NSAIDs. 

However the dosages that are needed to inhibit gastric acid secretion are higher than those for achieving cytoprotective effects, i.e. enhanced secretion of mucus and HCO3 . Its indication is mainly protection against NSAID-associated gastric ulceration. Only misoprostol 800 pg/day has been directly shown to reduce the risk of ulcer complications. 

The addition of proton pump inhibitors (PPIs) to treatment with conventional NSAIDs is probably the most cost-effective alternative for the prevention of gastrointestinal events. Addition of misoprostol is also a well-documented prophylactic routine. 

GI Age > 65 Previous ulcer Steroid treatment Treatment with more than one NSAID Scrutinize the indication, inform about the risks and choose another analgesic. Consider ulcer prophylaxis with proton pump inhihitors or misoprostol, or alternatively choose a COX-2 inhihitor... 

Uterus and pregnancy The whole pregnancy period Avoid NSAIDs in the last trimester. Use NSAIDs in first and second trimester only after careful consideration of possible risks (early miscarriages and malformations, respectively). Misoprostol is contraindicated throughout pregnancy... 

Geriatric Considerations - Summary Use of NSAIDs in older adults increases the risk of GI complications including gastric ulceration, bleeding, and perforation. These complications are not necessarily preceded by less severe GI symptoms. Concomitant use of a proton pump inhibitor or misoprostol reduces the risk for gastric ulceration and bleeding, but may not prevent long-term GI toxicity. No clinical data exist to support reduced GI toxicity with the use of diclofenac. 

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