Prevention

If patients need to continue NSAIDs, consider adding in misoprostol ^a

Why?

• Misoprostol is more effective than placebo at preventing gastric or duodenal ulcers in patients on long-term NSAIDs. However it causes diarrhoea ^a and more patients stop medication ^a . Larger doses (800 µg v. 400 µg) prevent ulcers more effectively but increase the risk of diarrhoea. ^a
• Misoprostol is more effective than ranitidine or proton-pump inhibitors at preventing endoscopic ulcers. ^a . The effect on symptomatic ulcers or recurrent GI bleeding is unclear.

Long-term NSAIDs: misoprostol is more effective than placebo, ranitidine or proton-pump inhibitors at preventing ulcers.

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
on NSAIDs for > 3 weeks a	misoprostol	placebo	gastric ulcers at 3-24 months	13%	0.25 (0.19 to 0.32)	11 (10 to 12)
			duodenal ulcers at 3-24 months	6.1%	0.45 (0.32 to 0.65)	31 (25 to 49)
			stopped medication at 3-24 months	30%	1.36 (1.26 to 1.46)	-15 (-20 to -12)
			diarrhoea at months	7.4%	2/73 (2.21 to 3.38)	-10 (-13 to -7)
	misoprostol	ranitidine 150 mg	endoscopic ulcers at 1-2 months	4.8%	0.28 (0.10 to 0.75)	29 (23 to 86)
	misoprostol	proton-pump inhibitor	endoscopic ulcers at 6 months	52%	0.59 (0.43 to 0.83)	8 (5 to 21)