Nonsteroidal anti-inflammatory drugs, or NSAIDs, are medications used to manage pain, fever, and inflammation. Common over-the-counter examples include ibuprofen and naproxen. While effective, their use is associated with a known risk of gastrointestinal (GI) bleeding, which is any bleeding within the digestive tract. This risk stems from how these medications function.
The Link Between NSAIDs and Stomach Damage
The primary action of NSAIDs involves inhibiting enzymes called cyclooxygenase (COX). The body has two main forms, COX-1 and COX-2. While COX-2 is involved in pain and inflammation, COX-1 produces prostaglandins that perform protective functions for the gastrointestinal lining. These prostaglandins stimulate a thick mucus layer, promote acid-neutralizing bicarbonate, and maintain healthy blood flow to the stomach wall for repair.
Most common NSAIDs are non-selective, meaning they block both enzymes. By inhibiting the protective COX-1 enzyme, these drugs weaken the stomach’s natural defenses. This leaves the lining vulnerable to damage from its own acid, which can lead to bleeding peptic ulcers.
Recognizing the Signs of a GI Bleed
The symptoms of a gastrointestinal bleed can range from obvious to subtle. One of the most distinct signs is vomiting blood (hematemesis). Fresh blood will be bright red, whereas blood that has been in the stomach may look dark brown and granular, often compared to coffee grounds.
Another key indicator involves changes in stool. Blood that has been digested results in black, tarry stools (melena). Bleeding that is slower or lower in the digestive tract may cause maroon-colored stools or have visible streaks of red blood.
A GI bleed can also cause other symptoms like sharp abdominal pain, weakness, dizziness, or unusual fatigue due to blood loss. Significant blood loss can also lead to shortness of breath and pale skin. Any of these symptoms warrant immediate medical evaluation.
Factors That Increase Bleeding Risk
Several factors can heighten the risk of developing a GI bleed while taking NSAIDs. The dose and duration of use are primary considerations, as higher doses and long-term use increase the probability of stomach damage. People over the age of 65 are more susceptible, as are those with a prior history of peptic ulcers or a previous GI bleeding event.
The concurrent use of other medications can amplify the risk. Taking NSAIDs with corticosteroids, anticoagulants like warfarin, or antiplatelet drugs like clopidogrel or daily low-dose aspirin interferes with the body’s ability to form clots. This means if an ulcer does develop, it is much more likely to bleed severely.
Not all NSAIDs carry the same level of risk. Some, like ketorolac, are associated with a higher incidence of GI complications. In response, selective COX-2 inhibitors like celecoxib were developed to target the inflammation-causing enzyme while having less effect on the protective COX-1 enzyme, though the risk is not eliminated entirely.
Preventative Measures and Alternatives
For individuals who need to take NSAIDs, several strategies can help minimize the chance of a GI bleed. The primary approach is to use the lowest effective dose for the shortest duration necessary to control symptoms.
For those at high risk who require long-term NSAID therapy, doctors often prescribe a second medication to protect the stomach. These gastro-protective agents include proton pump inhibitors (PPIs), such as omeprazole, or H2 blockers, like famotidine. These drugs work by reducing the amount of acid the stomach produces.
Exploring alternatives to oral NSAIDs can also be a valuable strategy. Topical NSAIDs in the form of gels or patches can deliver the medication directly to the area of discomfort with less systemic absorption. For chronic pain management, non-NSAID options like acetaminophen, physical therapy, and other lifestyle modifications can also be effective.
Diagnosis and Treatment Approaches
When a GI bleed is suspected, the primary diagnostic tool is an upper endoscopy. This procedure uses a thin, flexible tube with a camera to visualize the esophagus, stomach, and the first part of the small intestine. Blood tests are also run to check for anemia from blood loss, and stool samples may be tested for hidden blood.
Treatment begins with stopping the NSAID. To stabilize the patient, intravenous (IV) fluids are administered and high-dose IV PPIs are given to drastically reduce stomach acid.
If active bleeding is found during the endoscopy, treatment can be performed at the same time. Common techniques include thermal coagulation, which uses heat to cauterize the bleeding vessel, or the deployment of small metal clips to clamp it shut. In cases where a significant amount of blood has been lost, a blood transfusion may be necessary.