NSAR, Coxibe und Steroide: Wann und wie sollten Magen und Darm geschützt werden?

Zusammenfassung

Nicht-steroidale Antirheumatika (NSAR) haben ein hohes Risiko für gastrointestinale Komplikationen wie Ulzera, Ulkusblutungen oder Perforationen. Zudem verspüren 25-30% der Patienten Oberbauchbeschwerden (Dyspepsie). Die PPI-Komedikation zu einem NSAR kann die Rate an Ulzera, Blutungen und sonstigen Komplikationen sowie die Dyspepsierate senken. Ein anderer Ansatz zur Erhöhung der Sicherheit der Therapie ist die Verschreibung eines Cox-2-spezifischen NSAR (Coxib). Unter Coxiben treten seltener gastrointestinale Komplikationen einer NSAR-Therapie auf.

Die beiden präventiven Strategien, PPI-Komedikation zu einem nichtselektiven NSAR (nsNSAR) oder der Einsatz eines Coxibs, sind etwa gleich effektiv in der Verhinderung von symptomatischen Ulzera oder Ulkuskomplikationen (Blutung, Perforation). Coxibe verursachen seltener eine Anämie als die Kombination nsNSASR plus PPI. Die Kombination hingegen verursacht seltener dyspeptische Beschwerden als Coxib. Die Leitlinien empfehlen die PPI-Komedikation oder die Verschreibung eines Coxibs bei Patienten mit einem erhöhten gastrointestinalen Risiko. Hierzu gehören alle Patienten ab dem 65. Lebensjahr, Patienten mit einer Ulkusanamnese, Helicobacter pylori-Infektion, schweren Allgemeinerkrankung oder bei Komedikation mit Glucocorticoiden, gerinnungsaktiven Substanzen (Antikoagulation oder Thrombozytenaggregationshemmer) oder selektiven Serotonin-Reuptake-Inhibitoren (SSRI). Bei sehr hohem Risiko (Zusammentreffen mehrerer der genannten Risikofaktoren) ist die Kombination aus Coxib und PPI-Komedikation zu empfehlen.

Eine erfolgreiche Helicobacter-Eradikationstherapie senkt signifikant das Ulkusrisiko unter NSAR. Die aktuelle Leitlinie der deutschen gastroenterologischen Fachgesellschaft empfiehlt eine Helicobacter-Diagnostik und gegebenenfalls Therapie vor einer NSAR-Therapie bei allen Patienten mit Ulkusanamnese. Bei einem Ulkus oder Blutung unter NSAR soll ebenfalls eine Helicobacter-Diagnostik und gegebenenfalls eine Therapie erfolgen. Steroide als Monotherapie stellen nur ein geringes Ulkusrisiko dar, eine PPI-Prophylaxe wird nicht generell empfohlen. In der Kombination mit ASS oder NSAR steigt das Ulkusrisiko jedoch stark an und es sollte eine Ulkusprophylaxe durch PPI-Komedikation erfolgen.

Abstract

Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a high risk for gastrointestinal complications such as ulcers, ulcer bleeding or perforation. In addition, 25-30% of patients develop abdominal symptoms (dyspepsia). A proton-pump inhibitor (PPI), administered as a co-medication with an NSAID, reduces the rate of ulcers, bleeding and other complications as well as the rate of dyspepsia. Another approach to increase treatment safety is to prescribe a cox-2-specific NSAID (coxib) since coxibs are less commonly associated with gastrointestinal complications. Both the use of a PPI as a co-medication to a non-selective NSAID (nsNSAID) and the use of a coxib are equally effective in preventing symptomatic ulcers or ulcer complications (bleeding, perforation). The risk of anaemia is lower with coxibs than with the combination of nsNSAIDs and PPI co-medication, whereas the combination less frequently causes dyspepsia.

Guidelines recommend PPI co-medication or the use of a coxib in all patients with an increased gastrointestinal risk. The risk is increased in all patients older than 65, patients with a history of a peptic ulcer, helicobacter pylori infection, severe general illness, or in patients with comedication of steroids, anticoagulation, antiplatelet therapy or selective serotonin-reuptake-inhibitors. In patients with a very high risk (combination of several of these risk factors), the combination of a coxib and PPI co-medication is recommended.

A successful eradication therapy for helicobacter pylori leads to a significant reduction of the ulcer risk during treatment with NSAIDs. The current guideline of the German Society of Gastroenterology recommends checking for and treating helicobacter infections in all patients with an ulcer history prior to initiating NSAID treatment. In case of an ulcer or gastrointestinal bleeding during NSAID treatment, patients should also be checked for helicobacter and treated if positive.

The ulcer risk on monotherapy with glucocorticoids is only slightly increased. PPI co-medication is not generally recommended. However, in combination with aspirin or NSAIDs the ulcer risk increases very much and PPI should be prescribed as co-medication.

Schlüsselwörter

NSAD - COXIB - PPI - prophylaxe

Key words

NSAD - COXIB - PPI - prophylaxis

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