Some of the side effects of NSAIDs on the large bowel are rare, such as erosions, solitary or multiple ulcers, inflammation (which may resemble classic inflammatory bowel disease [IBD]), aggravation of diverticulitis, or even appendicitis in the elderly (Bjarnason et al, 1987). Treatment is the same as for the underlying disease, with discontinuation of the particular NSAID and with COX-2 selective agents being the preferred antiinflammatory analgesic.
One common and clinically relevant side effect of NSAIDs is to cause relapse of classic IBD. About 20% of patients with Crohn's disease or ulcerative colitis have a clinical relapse of their disease within 1 week of receiving conventional NSAIDs. This relapse is shown to be associated with escalating inflammatory activity (vastly increased fecal calpro-tectin). In these cases we discontinue the particular NSAID and give the patient a crash course of prednisolone (30 mg/d for 5 days, reducing the dose by 5 mg every 5 days). Within 4 to 5 days it is safe to give the patient the COX-2 selective agent nimesulide (Aulin),* because this drug is not associated with relapse of the disease (the safety of other COX-2 selective agents has not been formally tested). However, if the relapse occurs after 10 to 14 days of conventional NSAID treatment, it is most likely not due to the drug. In these cases we treat the relapse by conventional means and
^Editor's Note: Nimesulide (Aulin, Helsinn Healthcare, Switzerland) is not available in United State at this time.
continue the particular NSAID. However because of the "safety" of nimesulide in patients with IBD disease we have not used conventional NSAIDs lately in these patients. Low dose aspirin for cardiovascular prophylaxis and IBD? Yes, we belief that aspirin in doses of 150 mg/d or less are perfectly safe!
Overall it is important to be aware of the side effects of conventional NSAIDs on the lower gastrointestinal (GI) tract as they are widely used, despite the availability of COX-2 selective agents. Even when patients are at serious risk of gastric bleeding, many physicians place such patients on conventional NSAIDs with a proton pump inhibitor. Whatever the rationale for this combination, remember that it does not prevent the lower GI side effects of NSAIDs.
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