Welcome to another e-newsletter from the Center for Digestive Health & Nutrition. Our physicians, nurse practitioner, and registered dietician provide this information to help improve awareness in matters of health and nutrition. Each issue - which now goes out to over 13,000 readers - focuses on a particular topic that we feel will be of interest. I want to thank our readers for their positive feedback and suggestions for future topics.

If you use either a prescription or over-the-counter painkiller on a regular basis, you may have an increased risk for stomach problems, including bleeding ulcers. I wrote this issue of our patient newsletter after caring for a woman with a slowly bleeding ulcer who was surprised to learn that she had lost one-third of her blood. To see if you are also at risk, read on...

Joan M. is a 56 year old woman whom I was recently asked to see because of anemia, or low blood count. Joan recently noted trouble breathing when coming up from her basement laundry room and decided to see her family doctor. Routine blood tests revealed that her iron levels were low and and she was severely anemic (low red blood cell count). Her blood hemoglobin level, a measure of red blood cells, was only 8. A normal level is over 12, so Joan was surprised to learn that she had lost about a third of her blood. She reported no visible loss of blood, but a simple stool test was positive for traces of blood. Her only medical problem was mild osteoarthritis for which she took two Motrin a day, and like most adults she also took a baby aspirin to protect her heart. Joan was referred to us by her PCP. Fearing colon cancer, I performed a complete colonoscopy, or “lower scope” exam, of her colon which was normal. She then underwent an examination of her stomach, or “upper scope” test. Termed a "gastroscopy," this exam revealed a large deep ulcer in her stomach lining that was slowly bleeding. Joan was surprised to hear this as she denied ever having heartburn. In fact, she was proud of her “cast iron stomach.” She could eat everything and feel well. It was determined that her ulcer was caused by the combination of Motrin and aspirin which she immediately discontinued. After eight weeks of iron supplements and ulcer treatment, a repeat exam revealed that her anemia was gone and her ulcer was completely healed. Joan case is typical of a common condition called an “NSAID ulcer.”

What is an NSAID?
The term NSAID stands for Non-Steroidal Anti-Inflammatory Drug which is a class of powerful pain killers. NSAIDs have been around for a long time and have benefited millions of people. These compounds were first isolated over 200 years ago making NSAIDs the oldest and most widely used pain medication in history. Initially found in willow bark, now all NSAIDs are synthesized in the laboratory. Aspirin is the simplest NSAID.

(The term non-steroidal anti-inflammatory drug, or NSAID, was given to this class of drugs to distinguish them from the anti-inflammatory activity of steroids such as cortisone or prednisone.)

Because NSAIDs are so effective in reducing everyday aches and pains, over 30 million Americans take an NSAID each day. NSAIDs are most effective when treating mild to moderate arthritis, other musculoskeletal pains, inflammation, headaches, and fever.

About 20 NSAIDs are now available with a doctor’s prescription including drugs such as celecoxib (Celebrex), diclofenac (Voltaren) and nabumetone (Relafen). Three prescription NSAIDs—ibuprofen, naproxen and ketoprofen—also are available over-the-counter. The over-the-counter versions of these drugs are better known by names like Advil, Motrin, and Aleve. The only difference is that prescription versions are a higher strength than those purchased over the counter.

Side Effects of NSAIDs
Although they are generally safe, NSAIDs, like all drugs, do have potential side effects. The most common side effects are digestive. This is because NSAIDs decrease the body’s natural protection against stomach acid. There are a range of minor stomach problems that may occur such as nausea, acid indigestion, upset stomach, stomach pain, and heartburn. Of greater concern are problems such as stomach ulcers and complications of ulcers such as bleeding or even perforation of the stomach. This is not an uncommon problem. About 1 in 20 individuals taking NSAIDs will develop an ulcer. In fact, serious side effects of NSAIDs, such as stomach bleeding, result in more than 100,000 hospitalizations and thousands of deaths each year in the U.S.

How do NSAID ulcers form?
The acid within your stomach is a form of hydrochloric acid (HCl), a very powerful and corrosive liquid. You may recall all the precautions you had to take in high school chemistry class when handling this dangerous substance. It’s hard to believe that we all have hydrochloric acid within our bodies. Hydrochloric acid will burn your skin and can quickly liquefy tissue such as meat. When you eat meat such as a steak, this acid quickly turns those muscle fibers into a liquid - so that your intestines can absorb the nutrition.

Well, the wall of your stomach is also a form of meat. Why doesn’t this acid eat right though your stomach wall? This is because there is a special mucous barrier which protects your stomach’s lining. This protective inner barrier prevents the acid within the stomach from digesting the stomach itself. NSAIDs can break down this protective barrier allowing damage to occur. When this damage forms a crater, it is called an ulcer. Just as a pothole may become deep enough to hit a water pipe beneath the street, a deep ulcer may hit an artery causing a bleeding ulcer. An even deeper ulcer may perforate, or eat completely thorough the stomach wall spewing undigested food and acid into the abdominal cavity, another life-threatening condition.

Who is at greatest risk?
Everyone who takes NSAIDs is at some risk for developing side effects. There is no medical test that can tell for sure if you will develop an ulcer, and in most cases, there are no warning symptoms. NSAID ulcers can occur at any age, but in general, those at greatest risk are typically older individuals usually over the age of 60. A past history of an ulcer raises the risk. The risk is increased when taking multiple NSAIDs or NSAIDs for an extended period of time. Other associated medications can increase the risk of serious side effects. These would include “ blood thinners” like Coumadin, warfarin and Plavix, steroid-like medications such prednisone. Even taking small amounts of over-the-counter NSAIDs can increase your risk of developing stomach problems. This even includes taking daily, low-dose aspirin to prevent a heart attack or stroke.

Side effects in those taking NSAIDs can happen at any point in time. They can happen after taking only a few doses of NSAID or they can happen after several years of use. Interestingly, the risk of complications does not disappear over time. Patients who have taken NSAIDs for many years without side effects are still at risk .

"I have no heartburn so am I safe?"
Unfortunately, No. It is important to learn that about 80 percent of people who develop a bleeding ulcer from NSAIDs have no prior warning symptoms such as heartburn. Their first symptom may be severe intestinal bleeding - usually seen as either vomiting blood or severe rectal bleeding. Vomiting blood may not be red, but often has the appearance of coffee grounds due to the effects of stomach acid. As the blood makes it way down into the colon, the patient may experience diarrhea with a red-black tarry consistency. These are serious symptoms and should result in a trip to the nearest hospital emergency department.

How to reduce the risk
To reduce risk factors, patients first need to evaluate their need for chronic NSAID use. Do you really need to take this medication? The best way to reduce the risk of an NSAID is not to take an NSAID. Some mild forms of pain, particularly pain without inflammation, can be handled by using Tylenol (acetaminophen). Tylenol is not an NSAID and does not have the risk of developing these ulcers. Taking NSAIDs with food does NOT always help prevent the development of ulcers since once they get into blood stream, NSAIDS can decrease the stomach's repair mechanism.

If the NSAID is necessary, you need to reduce the dose to the lowest dose that effectively manages your pain. Try not to combine different types of NSAIDs if possible. A common troublesome combination is a daily baby aspirin and daily ibuprofen as in Joan's case.

Prevent an ulcer by blocking the acid
If an individual can’t stop taking an NSAID, one way to reduce the risk of ulcers is to add another drug called an acid blocker. That means taking one powerful drug to protect you from side effects of another. This "balancing act" is not a perfect solution, but it works very well.

Acid blockers work by reducing the amount of acid that is produced in the stomach. The most effective of these drugs are called Proton Pump Inhibitors, or PPI. These agents can be quite effective in reducing the risk of ulceration in patients who need NSAIDs. Common PPI are Prilosec, omeprazole, Prevacid, Aciphex, Protonix, Nexium, Zegerid, and Kapidex. Most of these require a doctor’s prescription, but omeprazole, Prilosec (Prilosec-OTC) and Prevacid (Prevacid-24HR) are now available in an non-prescription form. (These over-the-counter forms are as effective in preventing NSAID ulcers and much less expensive. For example, I have seen the generic Prilosec (called omeprazole) at Costco's for about $18 for 6 weeks worth of protection.)

Summary
While NSAIDs are very effective for managing pain and treating inflammation, there are risks. Avoiding NSAIDs when possible, using the lowest dose for the shortest amount of time, and realizing that combining NSAIDS with other drugs in this class is dangerous all can help. If one must take NSAIDs on a frequent basis, the addition of a daily PPI such as Prilosec OTC can markedly reduce one's risk. By being aware of your risk factors and discussing them with your doctor, you can minimize the risks. Your doctor can best decide if you need to add an acid-reducing medication to your daily routine.