The regular use of pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of peptic ulcers – sores that form in the stomach and surrounding portions of the gastrointestinal tract. The U.S. Food and Drug Administration (FDA) requires that the labels and package inserts of both prescription and over-the-counter NSAIDs contain warnings about gastrointestinal (GI) risks. Patients who frequently take NSAIDs and experience the symptoms of a peptic ulcer should seek medical attention.

NSAIDs are commonly used to reduce swelling and inflammation and to relieve pain and fever. They are a popular class of medications for patients with arthritis. These patients and others with chronic pain conditions use the drugs regularly and for lengthy periods of time. They may also be used for occasional pain relief. Although the risk of developing ulcers is greater with prolonged use or high doses of NSAIDs, even periodic, low-dose use carries some risk.

NSAIDs prevent pain by inhibiting the production of chemicals called prostaglandins. In addition to their role in pain and inflammation, prostaglandins help protect the delicate GI lining. In the stomach, this lining must be protected from the gastric juices that digest food. A complex, multilayered barrier protects the stomach lining with the following components:

• Mucus. Coats the stomach and duodenal lining and shields it from stomach acid.
  
  
• Bicarbonate. A chemical that neutralizes stomach acid.
  
  
• Circulation of blood to the lining of the stomach and duodenum. Aids in cell renewal and repair.

Prostaglandins stimulate the mucus, increase the bicarbonate production and also stimulate blood flow. All of these actions by prostaglandins keep the protective barrier intact. Since NSAIDs inhibit the production of prostaglandins, all of these mechanisms are hindered, weakening the barrier and allowing the digestive juices to damage the lining. This may result in ulcers.

Peptic ulcers are sores that form in the gastrointestinal lining due to injury by digestive juices. Peptic ulcers often cause burning pain in the upper abdomen. Other possible symptoms of peptic ulcers include nausea and vomiting, loss of appetite, unexplained weight loss and fatigue. It is important for people taking NSAIDs to recognize these symptoms and to report them to a physician.

Most peptic ulcers are caused by the bacterium Helicobacter pylori (H. pylori). Nearly all those not caused by H. pylori result from the use of NSAIDs. NSAIDs tend to cause peptic ulcers in the stomach (gastric ulcers) rather than the duodenum (duodenal ulcers). The opposite is true for H. pylori.

Peptic ulcers caused by NSAIDs usually heal after the medications are stopped. Any method of healing ulcers (e.g., H2 blockers, proton pump inhibitors) may be recommended to promote healing by diminishing acid. If H. pylori is present along with NSAID-induced ulcers, antibiotics will generally be used to treat the bacteria.

Surgery may be necessary if the ulcer does not heal, recurs after healing, or if complications (e.g., severe bleeding, perforation, obstruction) arise. Peptic ulcer complications are more common with NSAID-induced peptic ulcers than those that result from other causes.

According to the American College of Gastroenterology, the overall risk of serious GI problems in patients taking NSAIDs is about three times greater than in patients who do not take NSAIDs. These serious problems include peptic ulcer complications. Such serious, potentially life-threatening complications may even occur with no warning symptoms, especially in NSAID-induced ulcers. This may be at least partially due to the pain-reducing effects of NSAIDs.

NSAID-related damage can occur to the GI lining throughout the digestive tract, but occurs most often in the stomach and duodenum. Such damage generally results from frequent use of NSAIDs or high dosages of the medications. However, it may also occur in patients who only take NSAIDs occasionally or only take small doses of the drug.

When ulcers occur, it is generally recommended that patients stop using any NSAIDs. Alternative pain relievers, such as acetaminophen, may be used instead. Acetaminophen reduces pain and fever but does not reduce inflammation. Although it does not cause GI side effects, it does have its own set of risks. Patients are encouraged to discuss this and other alternatives to NSAIDs with their physicians.

Not all types of NSAIDs inhibit production of prostaglandins in the stomach lining. Newer versions, called COX-2 inhibitors, reduce pain with less likelihood of damage to the GI lining. However, COX-2 inhibitors have other drawbacks, such as an increased risk of heart attack and stroke (see Types and differences).