# Risk of Upper Gastrointestinal Bleeding and Perforation Differs Among NSAIDs

 

 

      DynaMed Weekly Update - Volume 5, Issue 27 

Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been known to increase the risk of upper gastrointestinal (GI) bleeding. Newer COX-2 inhibitors were introduced with the promise of reduced GI adverse effects.

A recent systematic review with data from 9 cohort and case-control studies with over 50,000 patients has rank-ordered the risks of upper GI bleeding and perforation associated with use of a number of different NSAIDs. The lowest risks were found for the COX-2 inhibitor celecoxib (Celebrex) (relative risk \[RR\] 1.42, 95% CI 0.85-2.4) and for the traditional NSAIDS ibuprofen (Motrin and others) (RR 2.69, 95% CI 2.2-3.3) and aceclofenac (RR 1.44, 95% CI 0.65-3.2). Aceclofenac is not available in the United States. The highest risks were associated with piroxicam (Feldene) (RR 9.94, 95% CI 6-16.5) and ketorolac (Toradol) (RR 14.54, 95% CI 5.9-36). Diclofenac (Voltaren), meloxicam (Mobic), indomethacin (Indocin), naproxen (Aleve), and ketoprofen (Oruvail) were all associated with intermediate risk.

For traditional NSAIDS as a class, risk varied with duration of use. The risk was highest within the first 30 days of use (RR 5.22, 95% CI 3.8-7.2) and lower, but still significantly increased, after more than a year of use (RR 2.9, 95% CI 2.2-3.8). The COX-2 inhibitor, rofecoxib (Vioxx), which was withdrawn from the market in 2004 for cardiovascular toxicity, was also reviewed and was classified as having lower relative risk than traditional NSAIDs ([Arthritis Rheum 2010 Jun;62(6):1592](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=20178131)).

For more information, see the [Acute upper gastrointestinal bleeding](http://search.ebscohost.com/login.aspx?direct=true&site=dynamed&id=116898) and [Prevention of NSAID-induced gastrointestinal toxicity](http://search.ebscohost.com/login.aspx?direct=true&site=dynamed&id=115775) topics in DynaMed.