Commentary: improving the use of gastroprotective agents among high-risk NSAID users


The recent publication by Ho and colleagues from Hong Kong[1] adds to the substantive body of work that this group has already contributed to the field of ulcer disease. Their 10-year, single-centre study included almost 14 000 consecutive patients with upper gastrointestinal bleeding (UGIB). Almost half had been taking aspirin and/or a nonsteroidal anti-inflammatory drug (NSAID). Looking at established risk factors for UGIB, only 41.6% of high-risk patients on an NSAID had been taking a gastroprotective agent before the bleeding episode; for those on aspirin, the figure was even lower at 30.6%. Most had been on an H2-receptor antagonist rather than on a proton pump inhibitor (PPI).

As the authors discuss, other investigators in different parts of the world have found similar results. Thus, despite our efforts at improving physicians’ co-prescribing habits, ulcer bleeding related to aspirin or NSAID use remains a major – and widespread – public health problem. The results from Hong Kong give further cause for concern. Through no fault of these investigators, many patients on aspirin and/or NSAIDs with identifiable risk factors for ulcer bleeding had not been optimally managed before hospitalisation. This is despite Hong Kong having a high prevalence of peptic ulcer, a presumably high level of awareness of this problem, and world-leading centres of excellence in all aspects of ulcer disease. What hope, one might ask, is there for the rest of us?

More optimistically, rates of gastroprotective agent co-prescription had been trending upwards in NSAID users (although not, apparently, in aspirin users). Among possible impediments to gastroprotective agent co-prescription is the perceived high cost of PPIs. It is hoped, this can be countered as costs should progressively decrease when cheaper generic agents become more available. We must continue to promote the simple, safe and sensible practice of PPI co-prescription for patients at high risk.


Declaration of personal and funding interests: None.