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NSAIDS Induced Bleeding - Risk Factors, Prevention, and Treatment

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NSAIDs (non-steroidal anti-inflammatory drugs) induced bleeding in the gastrointestinal tract is a common side effect. The article explains the condition.

Medically reviewed by

Dr. Abdul Aziz Khan

Published At February 3, 2023
Reviewed AtJuly 7, 2023

Introduction:

NSAIDs which stand for non-steroidal anti-inflammatory drugs are the most advised drugs in the world by healthcare professionals. However, one of the common side effects of these drugs is gastrointestinal bleeding. It occurs in patients with a history of peptic ulcer, are very old, or consume some other medications, especially antiplatelet agents.

The gastrointestinal bleeding induced by these NSAIDs can be prevented by using the lowest effective dose of the drugs, administration of COX-2 selective agents, or proton pump inhibitors. In cases of high risk of gastrointestinal and cardiovascular disorders, NSAIDs should be avoided.

What Are Non-steroidal Anti-inflammatory Drugs?

NSAIDs (non-steroidal anti-inflammatory drugs) are medicines that function as antipyretics, analgesics, and anti-inflammatories. They inhibit the enzymes responsible for prostaglandins, thromboxanes, and prostacyclins secretion. These enzymes are known as cyclooxygenases (COX) 1 and 2. The NSAIDs inhibit the COX-2 (cyclooxygenase-2) enzymes, and the side effects produced by these drugs are due to COX-1 (cyclooxygenase-1) inhibition.

The NSAIDs are classified into two categories:

  • Non-selective COX inhibitors inhibit both cyclooxygenase 1 and 2.

  • COX inhibitors are non-steroidal anti-inflammatory drugs that inhibit cyclooxygenase two inhibitors.

  • Aspirin functions differently from other NSAIDs as its inhibition of cyclooxygenase enzymes is irreversible.

What Are NSAIDs (Nonsteroidal Anti-inflammatory Drugs) Induced Bleeding?

NSAIDs increase the chances of side effects such as the formation of peptic ulcers and other gastrointestinal complications. These complications include bleeding, obstruction, or perforation in the gastrointestinal lining. Many studies have shown that upper gastrointestinal bleeding is more common in people taking NSAIDs rather than those who are not taking them. It is noticed that gastric ulcers are almost four times more common than duodenal ulcers or bleeding in NSAIDs-consuming cases. It was stated that Aspirin consumption, even at small doses for a long time, led to gastrointestinal bleeding.

This bleeding or other gastrointestinal tract complications occur due to prostaglandin inhibition. Prostaglandins are considered natural messengers which stimulate inflammation in the body. However, some prostaglandins are important to prevent the stomach lining from the adverse effects of stomach acid and promote a healthy condition of the gastrointestinal lining. Cyclooxygenase-1 (COX-1) enzymes secrete this prostaglandin. Non-selective non-steroidal anti-inflammatory drugs inhibit cyclooxygenase 1 and 2 and lead to a deficiency of useful prostaglandin for the stomach. This leads to side effects such as gastrointestinal bleeding, perforation, or obstruction.

What Are the Risk Factors for NSAIDs Induced Bleeding?

The severity of the bleeding depends on many factors, which are:

Age of the Patient: As age increases, the body’s mechanisms get slow, and thus the resistance of organs to inflammation also reduces. Older aged people with prolonged consumption of NSAIDs (most of the time Aspirin) are more prone to develop gastrointestinal bleeding.

History of Peptic Ulcer: Patients who develop peptic ulcers before in life due to any underlying reason are more susceptible to suffering gastric bleeding. This happens because the walls of the gastrointestinal tract are already weak due to the ulcer. If the protecting prostaglandin is not secreted, the acid can directly affect the ulcered lining and lead to bleeding.

Dosage of the NSAIDs: The risk of developing gastrointestinal bleeding depends on the dosage and duration of NSAID administration.

Combined Medication Intake: The chances of gastrointestinal bleeding increase in cases of taking more than one non-steroidal anti-inflammatory drug or combining it with glucocorticoids, anticoagulants, or selective serotonin-reuptake inhibitors. Glucocorticoids are steroid hormones that can be used to treat autoimmune diseases, inflammation, and cancer. Anticoagulants are medications that prevent blood clot formation. It is generally prescribed for cardiovascular conditions. Selective serotonin-reuptake inhibitors are one of the most commonly advised antidepressants by doctors. It was reported that using glucocorticoids alone never led to gastroduodenal bleeding. However, its use with NSAIDs increased the potential.

Aspirin: Low doses of Aspirin for a long duration are the treatment of choice in cardiovascular diseases. Administration of Aspirin and other drugs can lead to gastroduodenal bleeding in the patient.

H.pylori Infection: One of the common causes of stomach ulcers is Helicobacter pylori infection which leads to severe complications if the NSAIDs are administered along with it.

How to Treat NSAIDs-Induced Bleeding?

  1. The first line of treatment includes discontinuation of the NSAIDs, which will lead to prostaglandin secretion and the stomach lining's protection from acid.

  2. If the administration of NSAIDs is necessary, then it should be done along with H2 (hydrogen) blockers which will reduce stomach acid. Some commonly prescribed H2 (hydrogen) blockers or proton pump inhibitors are Omeprazole or Pantoprazole.

  3. Treatment of H. Pylori Infection: As it is stated that H. pylori infection is a risk factor that can induce bleeding of the stomach or intestinal lining by administration of NSAIDs, it is important to eradicate the bacteria from the gut. This can be done by prescribing antibiotics.

How to Prevent Nsaids-Induced Bleeding?

As the bleeding caused due to NSAIDs is dose-dependent, it is important to advise low doses of non-steroidal anti-inflammatory drugs. Also, the drug should preferably be combined with proton pump inhibitors to prevent more stomach acid secretion. There is a type of NSAID known as selective cyclooxygenase-2 (COX-2) inhibitors which inhibit only cyclooxygenase-2 and thus prevent inhibition of functional prostaglandin in the stomach.

Conclusion

NSAID-induced bleeding is caused primarily due to inhibition of prostaglandin secretion in the stomach, which prevents the gastrointestinal lining from stomach acid. The prolonged use of NSAIDs without proton pump inhibitors increases the chances of gastroduodenal bleeding. Thus it is important to regulate the dose of NSAIDs and combine it with H2 (hydrogen) blockers. H. pylori infection in the stomach also increases the risk of bleeding when administering NSAIDs. Thus its treatment is important.

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Dr. Abdul Aziz Khan
Dr. Abdul Aziz Khan

Medical oncology

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