NSAIDs and Peptic Ulcer Risk

Common prescription and over-the-counter painkillers could lead to ulcers.

Woman with stomach ache lying on the sofa
Westend61 / Getty Images

A peptic ulcer is the term used for a sore that occurs in the mucosal lining of the stomach, small intestine, or esophagus. When the ulcer is in the stomach it might also be called a gastric ulcer. Ulcers in the first part of the small intestine (duodenum) may be called a duodenal ulcer. The most common cause of a peptic ulcer is a type of bacteria called Helicobacter pylori (H pylori). A second, less common, but steadily increasing in importance, cause of peptic ulcers is the use of non-steroidal anti-inflammatory medications (NSAIDs).

Using over-the-counter NSAIDs, such as aspirin or ibuprofen for the occasional headache or achy back won’t cause a peptic ulcer. Rather, peptic ulcer disease is something that can occur with higher doses of NSAIDs that are used for a long period of time, such as for chronic pain that is associated with arthritis or other inflammatory conditions. People who have any concerns about the use of NSAIDs and how the digestive system will be affected should speak to a physician.

Why NSAIDs Cause Ulcers

NSAIDs such as aspirin, ibuprofen, and naproxen, can cause ulcers by interfering with the stomach's ability to protect itself from gastric acids. While stomach acids are vital to the digestive process, they can cause damage if the protective barriers of the stomach are compromised.

Normally, the stomach has three protections against gastric acid:

  • Mucus produced by foveolar cells that line the stomach
  • Bicarbonate produced by foveolar cells which helps neutralize stomach acid
  • Blood circulation that aids in the repair and renewal of cells in the stomach’s mucosal layer

NSAIDs slow the production of the protective mucus and change its structure. A class of lipids made by the body called prostaglandins have an affect pain receptors. NSAIDs work to reduce pain by blocking the enzymes that are involved in the production of certain prostaglandins.

Prostaglandins are also protective in the mucosal layer of the stomach, and when they are depleted, there can be a break in that layer. The suppression of the body's natural defenses against gastric acids can lead to inflammation in the stomach lining. Over time, this can cause the rupture of a capillary blood vessel, causing bleeding and the development of an open, ulcerative sore in the mucosal lining.

Symptoms of a Peptic Ulcer

A peptic ulcer may cause symptoms in the digestive tract but some people have no symptoms at all. The most common symptom is upper abdominal pain (where the stomach is located) that can feel dull or burning. The pain ranges in severity, with some experiencing mild discomfort and others having severe pain. Most of the time the pain will occur after a meal but for some people it might also occur at night. It could go on for anywhere from a few minutes to a few hours.

Other symptoms are less common but can include gas, nausea, vomiting, loss of appetite, weight loss, and feeling full after even a small meal. In rare cases, people with peptic ulcers may see blood in their stool or have stools that are black because they contain blood. Blood coming from one or more peptic ulcers could also be visible in vomit.

Diagnosing Peptic Ulcers

When the symptoms of a peptic ulcer are present, a physician may order several tests to determine the cause and confirm the diagnosis. In people who are receiving NSAIDs for chronic pain, a physician may already have a high suspicion that this is the cause of, or is contributing to, peptic ulcer disease. Because it is the most common cause of peptic ulcers, infection with H. pylori is normally ruled out through the use of a breath test or a stool test.

An upper GI series or an upper endoscopy might be used to look at the inside of the upper digestive tract and to look for ulcers.

In an upper GI, patients drink a substance called barium and a series of x-rays are taken. The barium helps the internal organs show up on an x-ray. During an upper endoscopy a flexible tube with a camera is used to look inside the esophagus, the stomach, and the duodenum. Patients are sedated during this procedure and small pieces of tissue (a biopsy) can be taken from the lining of the digestive tract for further testing.

Risk Factors

All NSAIDs have the potential to cause indigestion, gastric bleeding, and ulcers. However, some people are more susceptible to developing peptic ulcer disease than others. For instance, while studies suggest that as much as 25 percent percent of people receiving high-dose NSAIDs will develop an ulcer, only a small percentage of those will go on to develop serious complications.

Serious complications from peptic ulcers caused by NSAIDs are more likely to occur in people who:

  • Are older than 65
  • Also take corticosteroids
  • Have used NSAIDs for less than a month
  • Have a history of ulcers
  • Take high-dose NSAIDs
  • Have an infection with H. pylori
  • Use aspirin daily (including low-dose aspirin for cardioprotective purposes)
  • Also take blood thinners 

Treating Peptic Ulcers

It’s now known that spicy food and stress do not cause ulcers. However, there are some lifestyle changes that may be recommended in order to help heal peptic ulcers. A physician may recommend that a patient who has peptic ulcer disease stop smoking, avoid alcohol, avoid caffeine, discontinue the NSAIDs, and avoid any other types of foods that worsen symptoms.

In some cases medications might be prescribed to patients who take NSAIDs in order to prevent peptic ulcers from occurring in the first place. NSAID-induced ulcers usually heal once treatment with an NSAID is stopped. To speed up the healing process, a physician may recommend taking certain over-the-counter of prescription medications. An antacid, which can be obtained without a prescription, may be prescribed because it helps neutralize stomach acid. In some cases bismuth subsalicylate (such as Pepto-Bismol or Kaopectate) might also be used.

Prescription medications that might be recommended include an H2-blocker (histamine receptor blocker), which prevents the production of stomach acid through blocking histamine, and/or a proton pump inhibitor (PPI), which lowers the amount of acid in the stomach. Mucosal protective agents (MPAs) are another class of prescription drugs that might be used, and these medications work to keep the body producing the beneficial mucosal layer in the stomach..

The larger problem for people experiencing peptic ulcer disease as a result of therapy with NSAIDs is how to manage pain when those medications are discontinued. In the case of chronic pain, this may require the help of a team of specialists, including a pain management doctor. A class of medications called COX-inhibitors (cyclooxygenase inhibitors) might be used to control pain for some people. COX-inhibitors have been shown to work for pain relief and are associated with fewer digestive side effects than other types of NSAIDs. These drugs have been shown to have cardiovascular side effects, however, so it’s usually recommended that they be used at the lowest effective dose.

Most ulcers heal once the NSAIDs are stopped but in some cases surgery may be needed. This is more often the case when there are complications as a result of the ulcer, such as serious bleeding, perforation (hole in the stomach or small intestine), or an obstruction (bowel blockage).

A Word From Verywell

Most people who take NSAIDs will not experience peptic ulcer disease. However, people who have chronic pain and who are receiving high doses of these medications should be aware of the possibility of ulcers. In some cases, it might be appropriate to ask a physician if there are ways to prevent ulcers and if those measures should be put into place while receiving high doses of NSAIDs. Because untreated ulcers can lead to complications, it’s important to get a diagnosis and receive treatment right away if an ulcer is suspected. In most cases the ulcers will heal with stopping the NSAIDs and symptoms can be managed with lifestyle changes, but over-the-counter and prescription medications may also be used to speed up the process. If chronic pain continues to be an issue and there is a risk of developing NSAID-associated ulcers, dealing with the source of the pain and working with a pain management specialist to find other pain relief methods may be the best option.

Source:

Lanza, F, Chan F, Quigley E, et al. "Guidelines for prevention of NSAID-related ulcer complications." Amer J Gastroenterol. 2009;104:728-38. DOI: 10.1038/ajg.2009.115.

Larkai EN, Smith JL, Lidsky MD et al. Gastroduodenal mucosa and dyspeptic symptoms in arthritic patients during chronic nonsteroidal anti-inflammatory drug use. Am J Gastroenterol.1987;82:1153–1158.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). "Symptoms & Causes of Peptic Ulcers (Stomach Ulcers).” National Institutes of Health. Nov 2014.

Continue Reading