Peptic ulcer corticosteroids

Risk factors for NSAID-induced peptic ulcers and complications are presented in Table 15-2. Several important principles should be considered when estimating the risk for developing PUD in a patient taking an NSAID (1) risk factors are generally additive (2) some risk factors (e.g., corticosteroid therapy) are not by themselves a risk factor for ulceration but increase PUD risk substantially when combined with NSAID therapy and (3) many of the risk factors postulated to increase PUD... 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

Corticosteroid ADRs include the development, reactivation, perforation, hemorrhage, and delayed healing of peptic ulcers. 

Long-term use of oral corticosteroids may result in side-effects, such as peptic ulceration, adrenal suppression and subcapsular cataracts. 

WARNING May T risk of CV events GI bleeding Uses Osteoarthritis, RA, JRA Action NSAID w/ T COX-2 activity Dose Adults. 7.5-15 mg/d PO Feds (>2 y). 0.125 mg/kg/d, max 7.5 mg 4- in renal insuff take w/ food Caution [C, D (3rd tri) /-] Peptic ulcer, NSAID, or ASA sensitivity Disp Tabs, susp SE HA, dizziness, GI upset, GI bleeding, edema Interactions T Effects OF ASA, anticoagulants, corticosteroids, Li, EtOH, tobacco effects W/ cholestyramine 4-effects OF antihypertensives EMS T Effects of anticoagulants concurrent EtOH/tobacco use can T adverse GI effects (bleeding, D) T risk of photosensitivity Rxns OD May cause NA and lethargy activated charcoal may be effective... 

COX-2 specific inhibition good choice for patients with inflammatory conditions who are at high risk of gastrointestinal adverse effects (e.g., older than 60 years history of peptic ulcer disease prolonged, high-dose NSAID therapy concurrent use of corticosteroids or anticoagulants)... 

Contraindications Hypersensitivity to corticosteroids, administration of live virus vaccine, peptic ulcers (except in life-threatening situations), systemic fungal infection... 

Contraindications Administration of live virus vaccines, especially smallpox vaccine hypersensitivity to corticosteroids or tartrazine peptic ulcer disease (except life-threatening situations) systemic fungal infection Topical Marked circulation impairment... 

Conn HO, Poynard T. Corticosteroids and peptic ulcer meta-analysis of adverse events during steroid therapy. J Intern Med 1994 236(6) 619-32. 

Henry DA, Johnston N, Dobson A, Duggan J. Fatal peptic ulcer complications and the use of non-steroidal antiinflammatory drugs, aspirin, and corticosteroids. BMJ (Clin Res Ed) 1987 295 1227. 

Corticosteroids should be used cautiously in the presence of congestive heart failure, myocardial infarction, hypertension, diabetes mellitus, epilepsy, glaucoma, hepatic disorders, osteoporosis, peptic ulceration, and renal impairment. Children are more susceptible to these adverse effects. To avoid cardiovascular collapse, steroids must be given slowly by intravenous injection. Large doses produce Cushing s syndrome (with moon face and sometimes hirsutism). 

All NSAIDs have the potential to cause gastric and duodenal ulcers and bleeding through direct (topical) or indirect (systemic) mechanisms. Risk factors for NSAID-associated ulcers and ulcer complications (perforation, gastric outlet obstruction, GI bleeding) include increased age, comorbid medical conditions (e.g., cardiovascular disease), concomitant corticosteroid or anticoagulant therapy, and history of peptic ulcer disease or upper Gl bleeding. 

ASPIRIN IMMUNOMODULATING DRUGS- CORTICOSTEROIDS Corticosteroids 1 aspirin levels, and therefore there is a risk of salicylate toxicity when withdrawing corticosteroids. Risk of gastric ulceration when aspirin is coadministered with corticosteroids Uncertain Watch for features of salicylate toxicity when withdrawing corticosteroids. Use aspirin in the lowest dose. Remember that corticosteroids may mask the features of peptic ulceration... 

Because side effects can complicate the use of corticosteroids, a careful history and certain tests may be advisable, particularly if a patient may require prolonged ocular therapy. Steroids should be used with great caution in patients with diabetes mellitus, infectious disease, chronic renal feilure, congestive heart feilure, and systemic hypertension. Systemic administration is generally contraindicated in patients with peptic ulcer, osteoporosis, or psychoses. Topical steroids should be used with caution and only when necessary in patients with glaucoma. 

Contraindications to the use of adrenal steroids for suppressing inflammation are all relative, depending on the advantage to be expected. They should be used only for serious reasons if the patient has diabetes, a history of mental disorder or peptic ulcer, epilepsy, tuberculosis, hypertension or heart failure. The presence of any infection demands that effective chemotherapy be begun before the steroid, but there are exceptions (some viral infections, see above). Topical corticosteroid applied to an inflamed eye (with the very best of intention) can be disastrous if the inflammation is due to herpes virus. 

Peptic ulcer Aspirin, corticosteroids, nonsteroidal antiinflammatory drugs Risk of bleeding or perforation of ulcer... 

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