Cozzarini Wolfgang, Rath Johannes, Bauer Andreas, Györög Ina, Györög Manfred, Prenner Markus, Trianto Theodorus, Maderbacher Hermann, Höller Erik, Grusch Bernhard, Sebesta Christian
1. Medizinischen Abteilung, NO Zentrum für Rheumatologie, Humanisklinikum Niederösterreich, Stockerau.
Wien Med Wochenschr. 2003;153(13-14):295-303. doi: 10.1046/j.1563-258x.2003.03035.x.
Due to the extraordinary high prevalence of peptic lesions in the upper gastrointestine in the long-term treatment with nonsteroidal anti-inflammatory drugs, a prophylaxis in patients belonging to high-risk groups is essential. Misoprostol, proton pump inhibitors and histamine 2-receptor antagonists have been evaluated in prospective studies. The efficacy of Misoprostol is well documented, though its use in prevention is frequently limited due to side effects. Proton pump inhibitors are also well established, especially in the therapy of nonsteroidal anti-inflammatory drugs associated peptic ulcers and in consecutive secondary prevention. The histamine 2-receptor antagonist Famotidine in a high oral dosage is able to reduce the frequency of peptic lesions too, but not to the same degree as Misoprostol and proton pump inhibitors. It is very likely that helicobacter pylori eradication without any further mucosaprotective therapy will only decrease the incidence of upper gastrointestinal bleeding in low dose Aspirin application. In spite of controversial studies this eradication seems to be a useful additional therapy for ulcer prophylaxis in high risk groups. Selective Cyclooxygenase-2 inhibitors may become a promising alternative, from a pathophysiological perspective. However, to date there has been a lack of clear comparative studies with common nonsteroidal anti-inflammatory drugs plus mucosaprotecting agents. Daily therapy costs are higher with a Cyclooxygenase-2 inhibitor than using the traditional nonsteroidal anti-inflammatory drugs together with either proton pump inhibitors, histamine 2-receptor antagonists or Misoprostol--a fact that should be considered in primary therapeutic decisions. In the following review we will present the most important results of the different prophylactic and therapeutic modalities. On the basis of placebo-controlled, prospective studies on the one hand and the recommendations of the scientific societies on the other, a guideline for daily clinical practice will be suggested.
由于长期使用非甾体抗炎药导致上消化道消化性病变的发生率极高，因此对高危人群进行预防至关重要。米索前列醇、质子泵抑制剂和组胺2受体拮抗剂已在前瞻性研究中得到评估。米索前列醇的疗效已有充分记录，但其预防用途常因副作用而受到限制。质子泵抑制剂也已得到充分证实，尤其是在治疗非甾体抗炎药相关消化性溃疡及后续的二级预防中。高剂量口服组胺2受体拮抗剂法莫替丁也能降低消化性病变的发生率，但程度不如米索前列醇和质子泵抑制剂。在低剂量阿司匹林应用中，根除幽门螺杆菌而不进行任何进一步的黏膜保护治疗，很可能只会降低上消化道出血的发生率。尽管研究存在争议，但这种根除似乎是高危人群溃疡预防的一种有用的辅助治疗方法。从病理生理学角度来看，选择性环氧化酶-2抑制剂可能成为一种有前景的替代药物。然而，迄今为止，缺乏与普通非甾体抗炎药加黏膜保护剂的明确对比研究。环氧化酶-2抑制剂的每日治疗费用高于使用传统非甾体抗炎药联合质子泵抑制剂、组胺2受体拮抗剂或米索前列醇的费用——这一事实在初始治疗决策中应予以考虑。在以下综述中，我们将介绍不同预防和治疗方式的最重要结果。基于一方面的安慰剂对照前瞻性研究和另一方面科学协会的建议，我们将提出日常临床实践指南。
