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Dyspepsia - unidentified cause - Management
How do I manage dyspepsia in a person taking an NSAID who does not have alarm features?
- For people with dyspepsia and significant acute gastrointestinal bleeding, arrange immediate admission to hospital.
- For people with nonsteroidal anti-inflammatory drug (NSAID)-induced dyspepsia without alarm features:
- Do a full blood count if there are any features of anaemia.
- Prescribe, or advise the use of, an antacid or alginate for immediate relief of dyspepsia as required.
- Review and manage lifestyle factors known to exacerbate dyspepsia.
- Review and manage drugs (other than NSAIDs) known to increase the risk of gastrointestinal bleeding or exacerbate dyspepsia.
- Stop the NSAID if acceptable, and prescribe a proton pump inhibitor (PPI) for 1 month. Test and treat for Helicobacter pylori if symptoms recur.
- Offer alternative analgesia (e.g. paracetamol and/or opioids).
- When it is not acceptable to stop the NSAID:
- Prescribe a full-dose PPI for 1 month, and maintain treatment at a dose appropriate to the risk of gastrointestinal bleeding.
- Test and treat for H. pylori (if present).
- If possible, reduce the risk from NSAID use by reducing the frequency or dose of the NSAID or, substituting it for one less likely to cause gastrointestinal symptoms.
- Refer those people whose symptoms persist despite treatment.
Clarification / Additional information
- Table 1 shows the categorization of the gastrointestinal safety of various nonsteroidal anti-inflammatory drugs (NSAIDs) [CSM, 2002].
Table 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) and gastrointestinal safety.
Risk | NSAIDs | Comment |
|---|
High Risk | Azapropazone | Highest risk — use only as second-line agent for rheumatoid arthritis, ankylosing spondylitis and acute gout |
Intermediate Risk | Piroxicam Indometacin Ketoprofen Diclofenac Naproxen | Piroxicam may be associated with a higher risk than other NSAIDs in this group |
Low Risk | Ibuprofen | Lowest risk |
|
Basis for recommendation
- Stopping NSAIDs when possible: this is a pragmatic recommendation widely supported by experts [NICE, 2005].
- Maintenance treatment with a PPI to reduce the risk of recurrence of dyspepsia for people who continue to use NSAIDs: these recommendations are based upon evidence for the efficacy of PPIs at reducing the risk of dyspepsia in those taking a NSAID.
- Testing for Helicobacter pylori in people prescribed a PPI long term: these recommendations are based upon expert opinion (50 experts from 26 countries) published in the Maastrict Consensus Report [Malfertheiner et al, 2007]. They concluded that although there is a lack of evidence to support the treatment of H. pylori in people taking long-term PPIs, testing and treatment for H pylori is recommended because:
- It may reduce the risk of atrophic gastritis.
- It may reduce the risk of gastric cancer.
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