NSAIDs Smoking

A study of the risk factors for gastrointestinal perforation, a much less frequent event than bleeding, has confirmed that aspirin and other NSAIDs increase the risk of both upper and lower gastrointestinal perforation (OR 6.7, Cl 3.1-14.5 for NSAIDs) (53). Gastrointestinal perforation has been associated with other factors, such as coffee consumption, a history of peptic ulcer, and smoking. The combination of NSAIDs, smoking, and alcohol increased the risk of gastrointestinal perforation (OR 10.7, Cl 3.8-30) (SEDA-21, 97). 

O Patients with peptic ulcer disease should avoid exposure to factors known to worsen the disease, exacerbate symptoms, or lead to ulcer recurrence [e.g., non-steroidal anti-inflammatory drug (NSAID) use or cigarette smoking]. 

In summary, the true association between most dietary factors and the risk of colon cancer is unclear. The protective effects of fiber, calcium, and a diet low in fat are not completely known. Lifestyle factors such as NSAID use and hormone use appear to decrease the risk of colorectal cancer, whereas physical inactivity, alcohol use, and smoking appear to increase the risk of colon cancer. Clinical risk factors and genetic mutations are well-known risks for colon cancer. 

Co-morbid factors that increase the risk of NSAID-induced GI bleeding include history of ulcer disease, advanced age, poor health status, treatment with certain drugs (discussed later), long duration of NS AID therapy, smoking, and heavy alcohol use. Because of their renal effects, NSAIDs must be used with caution in... 

Answer Peptic ulcer disease is most frequently secondary to either Helicobacter pylori infection or use of NSAIDs. The patient does admit to NSAID use (naproxen), but should also be checked for concomitant H. pylori infection at time of endoscopy or by a serology test. If the patient was found to have H. pylori, an appropriate eradication regimen should be prescribed. The patient should also be counseled to avoid NSAIDs. The patient should be prescribed a proton pump inhibitor for 8 weeks to heal the ulcer. A repeat endoscopy should be done at that time to document ulcer healing and rule out gastric cancer. In addition, the patient should be counseled to stop smoking, which is a risk factor for more severe peptic ulcer disease. 

In an 11-year observational study in new users of non-selective, non-aspirin NSAIDs (n — 181 441) and an equal number of non-users there was no evidence of a protective effect of naproxen (50). During 532 634 person-years of follow-up there were 6382 cases of serious coronary heart disease (11.9 per 1000 person-years). Multivariate-adjusted rate ratios for current and former use of non-aspirin NSAIDs were 1.05 (95% Cl = 0.97, 1.14) and 1.02 (0.97, 1.08) respectively. Rate ratios for ibuprofen, naproxen, and other NSAIDs were 1.15 (1.02, 1.28), 0.95 (0.82, 1.09), and 1.03 (0.92, 1.16) respectively. There was no protection in long-term users with uninterrupted use the rate ratio among current users with more than 60 days of continuous use was 1.05 (0.91,1.21). When naproxen was directly compared with ibuprofen, the rate ratio in current users was 0.83 (0.69, 0.98). This study therefore seems to have shown no cardioprotective effect of naproxen. However, the study had a number of important limitations, including lack of information about some important confounders (smoking, obesity), possible exposure misclassification, and lack of information about over-the-counter use of aspirin. 

Martin DF, Montgomery E, Dobek AS, Patrissi GA, Peura DA. Campylobacter pylori, NSAIDS, and smoking risk factors for peptic ulcer disease. Am J Gastroenterol 1989 84(10) 1268-72. 

Schlienger et al. conducted a retrospective case control study from 1992-1997 to investigate if NSAIDs had the same cardiovascular benefit in prevention of AMIs.[154] A total of 3,319 cases with first time AMIs were determined and matched with 13, 139 controls based on age, gender, and practice and calendar time. After adjustment for other risk factors hke smoking, BMI, HRT and aspirin, there was a trend towards increased risk of AMI in NSAID users. The higher doses of NSAIDs were associated with significantly increased risk of MI as much as doubled. The authors concluded that NSAIDs was associated with an increased risk of AMI and no cardioprotection was observed with use of NSAIDs. 

Patients with peptic ulcer disease should reduce psychological stress, cigarette smoking, and nonsteroidal antiinflammatory drug (NSAID) use, and should avoid foods and beverages that exacerbate ulcer symptoms. 

Patients with peptic ulcer disease who develop recurrent ulcer signs or symptoms of Cl bleeding or perforation should be referred to a specialist. Assess reasons for therapeutic failure, including noncompliance to the drug regimen, antibiotic resistance (HPeradication), heavy smoking, NSAID use, and the need for HP eradication in a patient on conventional antiulcer medications. 

The natural course of chronic PUD is characterized by frequent ulcer recurrence. Approximately 60% to 100% of ulcers recur within 1 year of initial ulcer healing with conventional antiulcer regimens. The most important factors that influence ulcer recurrence are HP infection and NSAID use. Other factors include gastric acid hypersecretion, cigarette smoking, alcohol use, a long duration of PUD, ulcer-related complications, and patient noncompliance. The cause of ulcer recurrence is most likely multifactorial. 

The importance of psychological factors in the pathogenesis of PUD remains controversial. Clinical observation suggests that ulcer patients are adversely affected by stressful life events. However, results from controlled trials are conflicting and have failed to document a cause-and-effect relationship. It is possible that emotional stress induces behavioral risks such as smoking and the use of NSAIDs, or alters the inflammatory response or resistance to HP infection. The role of stress and how it affects PUD is complex and probably mnlti-factorial. 

Patients with PUD should eUminate or reduce psychological stress, cigarette smoking, and the use of nonselective NSAIDs (including aspirin). Although there is no antiulcer diet, the patient should avoid foods and beverages (e.g., spicy foods, caffeine, and alcohol) that cause dyspepsia or that exacerbate ulcer symptoms. If possible, alternative agents such as acetaminophen, nonacetylated... 

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