Lanas Angel, Sopeña Federico
Service of Digestive Diseases, University Hospital, University of Zaragoza, Instituto Aragonés de Ciencias de la Salud, CIBERehd, C/San Juan Bosco 15, 50009 Zaragoza, Spain.
Gastroenterol Clin North Am. 2009 Jun;38(2):333-52. doi: 10.1016/j.gtc.2009.03.007.
In addition to the upper GI tract, NSAIDs can damage the small bowel and the colon. NSAID enteropathy is frequent and may be present in more than 60% of patients taking these drugs long term. In most cases, damage is subclinical, including increased mucosal permeability, inflammation, erosions, ulceration, but other more serious clinical outcomes such as anemia, and overall bleeding, perforation, obstruction, diverticulitis and deaths have also been described. The magnitude of these serious outcomes from the lower GI tract is not well defined, but recent data suggest that they may be as frequent and severe as upper GI complications. Contrary to what happens in the upper GI tract, treatment and prevention of NSAID enteropathy is difficult, since the pathogenic mechanisms are different and not well understood. Among other options, misoprostol, antibiotics, and sulphasalazine have been proved to be effective in animal models, but they have not been properly tested in humans. Selective COX-2 inhibition is emerging as a potential alternative to tNSAIDs in the prevention of damage in the lower GI tract in rheumatologic patients. Preliminary studies in healthy volunteers have shown that these drugs are associated with no or less small bowel damage than tNSAIDs plus PPI, although their long-term effects in patients need to be properly tested. Post hoc analysis of previous outcome studies focused on complications of upper GI tract or cardiovascular events have shown contradictory results. Data from one ongoing trial comparing celecoxib versus diclofenac plus PPI and examining serious outcomes from the whole GI tract will probably provide new insights in this area.
除了上消化道，非甾体抗炎药还会损害小肠和结肠。非甾体抗炎药肠病很常见，长期服用这些药物的患者中可能有超过60%出现这种情况。在大多数情况下，损害是亚临床的，包括黏膜通透性增加、炎症、糜烂、溃疡，但也有其他更严重的临床后果，如贫血、全身出血、穿孔、梗阻、憩室炎和死亡的报道。下消化道这些严重后果的严重程度尚不清楚，但最近的数据表明，它们可能与上消化道并发症一样常见和严重。与上消化道的情况相反，非甾体抗炎药肠病的治疗和预防很困难，因为致病机制不同且尚未完全了解。在其他选择中，米索前列醇、抗生素和柳氮磺胺吡啶在动物模型中已被证明有效，但尚未在人体中进行充分测试。选择性环氧化酶-2抑制作为传统非甾体抗炎药的一种潜在替代方法，正在出现以预防风湿病患者下消化道的损害。对健康志愿者的初步研究表明，与传统非甾体抗炎药加质子泵抑制剂相比，这些药物导致的小肠损害较少或无损害，尽管它们对患者的长期影响需要进行充分测试。之前对上消化道并发症或心血管事件的结局研究的事后分析结果相互矛盾。一项正在进行的比较塞来昔布与双氯芬酸加质子泵抑制剂并检查全消化道严重后果的试验数据可能会为该领域提供新的见解。
