• People are at high risk of serious nonsteroidal anti-inflammatory drug (NSAID)–induced gastrointestinal (GI) adverse events if they have one or more of the following risk factors:
• Age 65 years or older.
• History of gastroduodenal ulcer, GI bleeding, or gastroduodenal perforation.
• Concomitant use of medications that are known to increase the likelihood of upper GI adverse events (e.g. anticoagulants, aspirin [even low-dose], corticosteroids, and selective serotonin reuptake inhibitors [SSRIs], venlafaxine, or duloxetine).
• Serious comorbidity, such as cardiovascular disease, hepatic or renal impairment (including dehydration), diabetes, or hypertension.
• Requirement for prolonged NSAID use, including people with:
• Osteoarthritis or rheumatoid arthritis of any age.
• Chronic low back pain and 45 years of age or older.
• Use of the maximum recommended dose of an NSAID.
• Additional risk factors for NSAID-induced GI adverse events have also been identified, including:
• The NSAID used.
• The presence of Helicobacter pylori infection.
• Excessive alcohol use.
• Heavy smoking.

In depth

• In all people, consider using:
• An alternative to an NSAID, for example:
• For pain: paracetamol, with or without codeine.
• For gout: colchicine.
• For osteoarthritis: other analgesics, physical treatments (including exercise), surgery.
• For rheumatoid arthritis: optimization of disease modifying drugs (DMARDs). (Usually requires referral.)
• Only one (oral or topical) NSAID at a time. When possible, avoid concomitant use of an NSAID with low-dose aspirin. Low-dose aspirin for cardiovascular protection almost always has priority over an NSAID.
• The lowest NSAID dose that is compatible with symptom relief.
• In people who are at increased risk of gastrointestinal (GI) adverse effects and require an NSAID, prescribing options are:
• A standard NSAID with a proton pump inhibitor (PPI) prescribed at a dose licensed for gastroprotection (see Table 1).
• A coxib with a PPI.
• For people who have an NSAID-associated peptic ulcer, see the CKS topic on Dyspepsia - proven peptic ulcer.

In depth

• The management of gastrointestinal adverse effects in a person using a nonsteroidal anti-inflammatory drug depends on whether they have been investigated (e.g. with endoscopy or a test for Helicobacter pylori) and whether 'alarm' symptoms are present. For full details, see the CKS topics on:
• Dyspepsia - pregnancy-associated
• Dyspepsia - proven non-ulcer
• Dyspepsia - proven peptic ulcer
• Dyspepsia - unidentified cause
• For advice on how to manage people taking low-dose aspirin who develop gastrointestinal adverse effects, see the CKS topic on Antiplatelet treatment.

In depth