NSAIDs and gastrointestinal mucosal injury

Nonsteroidal anti-inflammatory drugs including low-dose aspirin are the most important cause of gastrointestinal (GI bleeding) worldwide. While advances in potent acid suppressive therapy have been shown to reduce the risk of upper GI bleeding with NSAID use, there is no reduction in the mortality of NSAID-associated GI bleeding for a number of reasons. The latter include old age, multiple comorbidites, use of complex therapy including combination of ASA and anti-thrombotic drugs such as other anti-platelet drugs and anti-coagulants, and NSAID/ASA-associated lower GI bleeding. There is good evidence that most patients died of their underlying comorbidities despite successful control of GI bleeding. This observation highlights the importance of preventing the occurrence of GI bleeding among the elderly. As the need of elective endoscopy in patients on anti-thrombotic drugs is increasing, appropriate peri-endoscopic management of anti-thrombotic therapy in patients undergoing endoscopy is essential to preventing GI bleeding. Another major challenge is the prevention of NSAID-associated lower GI bleeding. Both duration of hospitalization and mortality of lower GI bleeding are higher than that of upper GI bleeding. To date, there is no effective strategy for the prevention of small bowel bleeding with NSAID or ASA use. Furthermore, prevention of delayed post-polypectomy bleeding in patients receiving anti-thrombotic therapy is another clinical challenge.