Dear Gaurav Kumar Sharma,

Thank you for sharing your question, but I am not sophisticated in this issue.

Regards, 

Mehdi

Me also.

Dear Gaurav,

Anti-acids are best suited for short term/immediate relieve of heartburn and not commonly co-prescribed with NSAIDs since the adverse effects of NSAIDs occur after a prolonged usage. On the other hand, PPI are preferred for long term management and healing of GERD, erosive esophagitis and peptic ulcers. Co-prescription with NSAIDs has been practiced among physicians, Orthopaedics and cardiologists. Most common combinations include NSAID with Pantoprazole, Esomeprazole and Omeprazole. On the basis of efficacy, esomeprazole has a good profile while on the basis of drug-drug interaction, pantoprazole has been reported to have lesser drug-drug interaction.

The rationale for combining NSAID and PPI should be based on the specificity of your NSAID for COX-2, found predominantly at sites of inflammation and for COX-1, in the gastrointestinal tract.

PPl drug-drug interactions should be put to consideration too.

Regards.

I shortly summarize my evidence based response as follows:

1. If there is already an ulcer developed due to NSAID and the NSAID should continue, PPIs are the only effective cotherapy to cure the ulcer as well as to prevent recurrence.

2. If ulcer is not yet developed but there is high moderate to high risk of developing ulcer, PPIs, H2B or misoprostol can be effective cotherapy options to prevent ulcer.

3. If ulcer is developed due to NSAID but NSAID is to be discontinued, then sucralfate, PPI or H2B can be used to heal the ulcer.

Short answer:  You can prescribe any antacid or acid-reducer (PPI) with any NSAID.  Any combination of these will be 'safe'.

Long answer:  If your patient is already taking an NSAID and/or must take one long-term, start with a chewable antacid such as TUMS. If this doesn't work, try the following, in order of preference, lowest dose first, and increase to effectiveness:

Mylanta / Gaviscon / Maalox liquid  (NEVER use pepto-bismol or other salycilate)

bicarbonate

sucralafate - RX only, not an antacid, only a 'protective'

Pepcid (famotidine)

Zantac (ranitidine)

Prilosec (omeprazole)

Protonix (pantoprazole) - RX only but cheap

Prevacid (lansoprazole)

Nexium (esomeprazole) - OTC but expensive

Kapidex / Dexilant (dexlansoprazole) - most expensive

misoprostol / diclofenac - combination RX only drug

change NSAID to topical diclofenac

Even longer answer: PPI are almost too effective at reducing stomach acid, which is necessary for digestion and activation of some pro-drugs and dissolution of some vitamins.  Food without acid delays gastric emptying times, rots in the stomach, irritates the stomach lining, grows H.pylori, and triggers MORE indigestion and heartburn. The ultimate issue is protecting the _lining_ of the stomach from thinning due to COX-1 inhibition. A PPI may actually make ulcers WORSE by letting food rot in the stomach and physically irritate a thin stomach lining. In this respect, an H2 antagonist / antihistamine like famotidine/ ranitidine may be safer and more effective to relieve heartburn / indigestion in a patient taking NSAID chronically. The H2-antagonists allow some acid, can be taken at bedtime to focus on nocturnal GERD (which can cause asthma).

Your patient may be better served to find other options for chronic pain or inflammation besides an NSAID, or change their diet to promote better GI health rather than just simply take away all their stomach acid.  Have them eat less meat, eat meat that isn't charred or black (causes inflammation and cancer), more vegetables, take probiotics, don't eat late at night, low fat, less spicy or acidic food (juice, tomato sauces), less alcohol or at least no alcohol with supper or later.   Have your 1 glass of red wine with lunch, instead. Drink plenty of water during daytime. Less fried foods (they promote GI inflammation), and less processed foods.

Dear Gaurav Kumar Sharma,

This is a good question, theoretically you may think of PPI as a first choice, but to really have a good clinical practice (I mean clinically) you need to consider patient risk factors and/or if they have previous history of  NSAIDs associated stomach or GIT problems . SO CLINICALLY, and for prophylactic treatment (as I understand from your question that what is best for prevention for those on long term treatment of NSAIDs?)

1) If the patient is at low risk of developing NSAIDs associated GIT problems with no history NSAIDs associated stomach or GIT problems maybe the most cost-effective treatment will be just antacid.

2) moderate-high risk without history, I will recommend Omeprazole or any available/cost effective PPI

3) if the patient has a known history NSAIDs associated stomach or GIT problems or at high risk, then I will recommend 40 mg Esomeprazole (as 20 mg failed to show superiority over other PPIs) orally or in very few cases need I.V (but I.V is not as part of prophylactic treatment, instead it is for sever cases of reported NSAIDs associated GIT problems or when the oral rout is not possible which needs I.V at hospital then discharge on oral treatment again).

I tried to simplify the answer based on my clinical evidenced based experiences for hospital/clinical practices purposes and this may not be applicable for teaching or academic purposes.

So to summarise: in order to choose PPI or not it depends mainly upon patient risk factors and known history of NSAIDs associated GIT problems 

Regards,