NSAID ulcer risk is from systemic action, NOT contact of pills with the pouch

This has come up a lot again lately, so I wanted to post (again) an explanation of why it makes absolutely NO difference what form the NSAIDs are in in terms of the risk of ulcers. The danger is from the systemic action of the drugs, not from the direct contact of the drug with the pouch or stomach. Once in your body, it causes thinning of the lining of the stomach and pouch which can lead to ulcers and/or bleeding.

If the issue was direct contact, people wouldn't get ulcers in their remnant stomach which clearly cannot come into contact with anything. Also, although the chances are small, you CAN get an ulcer from just one dose of a NSAID, especially if it is a high-powered Toradol shot (which I once heard referred to as "an NSAID on steroids", LOL). One of the members of OH who was very active a few years ago got one from that very thing: one single dose of Toradol.

Because even some medical professionals -- some doctors, but more frequently nurses -- are not aware of this (or have forgotten it), people seem particularly reluctant to believe it (and say things like "my doctor said caplets are safe to take", "it was a shot so they told me it wouldn't be a problem", etc.).

Ok, so don't take MY word for it (or Kelly's, or any of the other vets who have posted about this numerous times). Take the word of medical studies and journal publications. I have included the source for each, but have included only the relevant conclusion information. If you want more detail, you will have to go out to the individual documents. All of them at least have free abstracts available on the Internet, even if the entire article is not available for free.


1. From "NSAIDs (including aspirin): Pathogenesis of gastroduodenal toxicity" http://www.uptodate.com/contents/nsaids-including-aspirin-pa thogenesis-of-gastroduodenal-toxicity?source=outline_link&vi ew=text&anchor=H2782934#H2782934

"However, this "topical" epithelial injury by many NSAIDs does not appear to be of prime importance in the pathogenesis of clinically important endpoints (symptomatic ulcers) [2]. The pathogenesis of symptomatic peptic ulcer disease caused by exposure to NSAIDs is mainly a consequence of systemic (post-absorptive) inhibition of GI mucosal cyclooxygenase (COX) activity. Even intravenous or intramuscular administration of aspirin or NSAIDs can cause gastric or duodenal ulcers in animals and humans [3-5]."
 

2. From "Peptic ulcerations are related to systemic rather than local effects of low-dose aspirin" Clin Gastroenterol Hepatol. 2008 Mar;6(3):309-13. doi: 10.1016/j.cgh.2007.12.018. Epub 2008 Jan 31.

"This implicates that peptic ulcers seem to be related to systemic rather than to local effects of low-dose acetylsalicylic acid."



3. From "Managing the Adverse Effects of Nonsteroidal Anti-inflammatory Drugs"
Paola Patrignani, Stefania Tacconelli, Annalisa Bruno, Carlos Sostres
Expert Rev Clin Pharmacol. 2011;4(5):605-621.

"NSAIDs injure the gut by causing topical injury to the mucosa and by systemic effects associated with mucosal prostaglandin depletion derived from COX inhibition (Figure 3). Platelet inhibition has also been considered to be a key mechanism of bleeding of lesions of the GI tract. The systemic effects of NSAIDs appear to have a predominant role, since visible topical injury disappear with continuous use of NSAIDs in most cases, but ulcers and complications may continue to develop. This systemic effect may be the reason why the use of enteric-coated aspirin preparations and parenteral or rectal administration of NSAIDs, in order to prevent topical mucosal injury, has not been successful to prevent the development of gastroduodenal ulcers and their complications."

There ARE studies that show that Celebrex is safer than most NSAIDs and that less of the drug is absorbed into the system with topical preparations such as Voltaren gel (but it still comes with a warning about the risk of ulcers). So, no matter what form you take it in, taking NSAIDs does pose the risk of ulceration, especially in the pouch which does not have all of the gastric "juices" that the stomach has (which are partly protective).


Lora

(updated to add hyperlink to item #1)

I have a non-bypass friend *****cently had a bout of diverticulitis followed by another painful infection. They would not let her have any nsaids until they were positive the diverticulitis was cleared up because of the risk of thinning the tissues of the colon. It is a very real problem.

Good Article

 

My Dr prescribes the protectant Carefate for 90 days if a person were to need NSAIDS.

Even some normal stomach people susceptible to ulcers are told no NSAIDS. Will any of ever take one? Oh I'm sure, I have taken one a few times because that's all that was available but I don't make it a habit doing it.



Great info!

Did you by chance find any articles/journals that discuss the % increased risk of developing an ulcer in post-op RNY patients with NSAID's? I am curious to know how elevated the risk is compared to those who do not have the altered anatomy.

I don't think the risk is actually elevated, but rather the problem is the potential for an ulcer to develop in the blind stomach which would make such an event a lot tougher to diagnose and treat properly.  It's not like if you take an NSAID post-RNY you WILL develop an ulcer, one just needs to exercise extra precaution because if such an event were to occur, it could require an abdominal surgery rather than a simpler oral/esophageal procedure.  

For what it's worth, my surgeon said that even if one were to take an NSAID via suppository, it could cause a stomach ulcer.  This just left me wondering who sticks ibuprofen up their butt!  :D

Jen

You may be right about the risk not being particularly elevated (although the limited gastric juices in the pouch would certainly elevate it some).

An ulcer in the remnant stomach definitely is the greatest concern.

Lora

The French!   I lived in Paris for two years and they love taking everything medicinal up the chuff LOL!

That is hilarious because my surgeon mentioned France when he told me that!  I guess taking pain meds orally is too gauche?  
:D

Jen

No.  I have seen statistics on the incidence of ulcers in RNYers (although many of those are marginal ulcers at the ananstomosis), but don't have any idea what the incidence of ulcers is in the general population to use for comparison.

Lora