Peptic Ulcers - Risk Factors

Risk Factors for NSAID-Induced Ulcers

Between 15% and 25% of patients who have taken NSAIDs regularly will have evidence of one or more ulcers, but in most cases they are very small. Given the widespread use of these drugs, however, the total number of people with serious problems may be considerable. Long-term NSAID use can cause damage to the stomach and possibly the small intestine.

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In April 2005, the FDA asked drug manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes an increased risk for cardiovascular events and gastrointestinal bleeding in people taking these drugs. The FDA also requested manufacturers of OTC NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions

High-Users of NSAIDs. Anyone who uses NSAIDs regularly is at risk for gastrointestinal problems. Even low-dose aspirin (81 mg) used to protect the heart may pose some risk (although lower than standard doses). In one study, over a four-year period, 4.5% of regular uses were hospitalized for GI bleeding. The highest risks, however, are in people who require long-term use of very high doses, notably people who suffer from arthritis, particularly rheumatoid arthritis. Others that have a high intake of NSAIDs, include, but are not limited to, people with chronic low back pain, fibromyalgia, and repetitive stress .

Contributing Factor s. Certain factors add to the risk for ulcers in NSAID-users:

Peopleolder than age 65.
Anyone with a history of peptic ulcers or upper gastrointestinal bleeding.
Those with other serious ailments, such as heart disease or congestive heart failure.
NSAID users who also take certain other medications, such as the anticoagulant warfarin (Coumadin), corticosteroids, or the osteoporosis drug alendronate (Fosamax).
Alcohol abusers. Excessive alcohol use may intensify the risk of bleeding in those who also take NSAIDs. (Some studies have shown that alcohol may actually protect against H. pylori.) In any case, everyone should avoid excessive use of alcohol.
People who take NSAIDs and are infected with the H. pylori bacteria. A 2002 study reported that the combination poses a 3. 5-fold greater risk of ulcers than either one of these factors. (Not all studies report the higher risk in infected patients.)

Other Risk Factors for Ulcers from Either H. Pylori or NSAIDs

Stress and Psychological Factors. Although stress is no longer considered to play a causal role in ulcers, studies still suggest that stress may predispose someone to ulcers or help sustain existing ulcers. Some experts, in fact, estimate that social and psychological factors play a contributory role in 30% to 60% of peptic ulcer cases, whether they are caused by H. pylori or NSAIDs. In any case, some experts believe that the anecdotal relationship between stress and ulcers is so strong that attention to psychological factors is still warranted.

Smoking. Smoking increases acid secretion, reduces prostaglandin and bicarbonate production, and decreases mucosal blood flow. Results of studies on the actual effect of smoking on ulcers, however, are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One study reported that after ulcers healed, about half of nonsmokers relapsed after a year, but that all heavy smokers relapsed after three months. Other studies have found no increased risk for ulcers in smokers. In any case, any impact of smoking on ulcers does not seem to be affected by the presence of H. pylori. This should not give smokers any comfort, however, given the other proven dangers from smoking.

Tobacco use and exposure may cause an acceleration of coronary artery disease and peptic ulcer disease. It is also linked to reproductive disturbances, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing.