New guidelines for health care providers require a thorough patient risk assessment that includes a careful examination of the patient’s medical history before prescribing NSAIDs. Whenever possible, physicians are to prescribe lower dosages of NSAIDs, limit the duration of NSAID use, treat any existing H. pylori infection prior to prescribing NSAIDs and institute any other necessary protective measures, such as prescribing alternative or additional medications.

Patients taking prescription or over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) should talk to a physician about the risk of peptic ulcers and other gastrointestinal (GI) side effects. Reduced dosages and alternative or additional medications may reduce these risks. The benefits of these medications must be weighed against their risks.

Various other pain relievers may be used as alternatives to NSAIDs. Among the most popular of these is acetaminophen. This medication reduces pain and fever but does not reduce inflammation. However, is also does not cause GI side effects. Acetaminophen is considered safe, but, like other drugs, it may cause problems when taken in high doses. It is included in many pain and cold medications. Patients with chronic liver disease are more prone to acetaminophen liver toxicity. Many patients take more acetaminophen than they realize. Because of this, it is important to inform physicians of all medications taken, including over-the-counter medications.

It is not always possible to stop taking NSAIDs. These medications can be an important part of therapy for many chronic pain conditions (e.g., arthritis), to the point that eliminating them is not a viable option. Further, aspirin has been shown to help prevent heart attack and perhaps stroke. These benefits can be obtained with a small daily dose. Such a dose poses a significantly reduced risk for GI problems. In patients at high risk of heart attack and stroke, aspirin’s benefits may outweigh the potential GI risks.

The risk of GI side effects with NSAIDs varies. Most patients can take occasional NSAIDs without increasing their risk of peptic ulcers. In general, most patients at low risk are usually not advised to take additional medications to reduce the GI risks. In some cases, there are enough risk factors that warrant continued monitoring and active preventative measures. These risks include:

• Age. Patients over 60 years of age have a much greater risk of developing peptic ulcers.
  
  
• Previous ulcer. Patients with a history of ulcer disease have an increased chance of developing subsequent ulcers.
  
  
• Dosage. Patients who take higher dosages of NSAIDs have a greater risk of developing peptic ulcers.
  
  
• Cigarettes and alcohol. Alone, both can cause GI irritation. NSAID use added to this irritation may result in elevated GI risks.
  
  
• Steroids. The combined use of NSAIDs and corticosteroids greatly increases the risk of gastrointestinal bleeding, according to the American College of Gastroenterology (ACG).
  
  
• Anticoagulants. According to the ACG, combined use of NSAIDs and oral prescription anticoagulants substantially increase the risk of GI bleeding.

When the risk of adverse effects is high and NSAIDs are still required, reducing the dosage or changing or adding medications may help prevent peptic ulcers. Not all NSAIDs have the same degree of GI risk. COX-2 inhibitors (e.g., celecoxib) have a lower risk of peptic ulcers and other GI problems (although they carry other risks - see Types and differences) than traditional NSAIDs. Other low-risk NSAIDs include ibuprofen and diclofenac. Medium risk NSAIDs include naproxen, indomethacin and piroxicam. High-risk NSAIDs include ketoprofen.

In certain high-risk cases, medications used to treat ulcers may be prescribed with NSAIDs to reduce the chance of developing the ulcers. Proton pump inhibitors may be the more useful of these. H2 blockers can prevent duodenal ulcers, but not gastric ulcers. The medication misoprostol may also be an option. This is a synthetic prostaglandin that replaces the prostaglandin responsible for protecting the stomach. Misoprostol has been successfully used to prevent peptic ulcers in patients taking NSAIDs, but is more expensive than proton pump inhibitors.

Research also indicates that the acid-reducing drug esomeprazole magnesium may reduce ulcer risk in NSAID users with an increased risk of developing ulcers.