Prevention

If patients need to continue NSAIDs, consider adding in a regular proton-pump inhibitor ^a  

Why?

• Proton-pump inhibitors are more effective than placebo or H₂ antagonists at preventing endoscopic ulcers. ^a Higher doses are more effective at controlling symptoms. ^a . There is no clear increased risk of stopping proton-pump inhibitors compared with placebo. ^a
• Regular pantoprazole given to elderly patients on long-term NSAIDs leads to less severe gastrointestinal damage than a course of H.pylori eradication therapy. ^a Regular omeprazole leads to fewer recurrent GI bleeds than a course of eradication therapy for patients on naproxen, but not clearly for patients on low-dose aspirin. ^a

Long-term NSAIDs: proton-pump inhibitors prevent endoscopuc ulcers more effectively than placebo or H₂-antagonists

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
on NSAIDs for > 3 weeks a	proton-pump inhibitors	placebo	endoscopic gastric ulcers at 3-12 months	21%	0.31 (0.20 to 0.48)	8 (6 to 10)
			endoscopic duodenal ulcers at 3-12 months	11%	0.19 (0.10 to 0.36)	12 (10 to 15)
	proton-pump inhibitors	H2-antagonists	procedure required for uncontrolled bleeding/ rebleeding at  days	21%	0.28 (0.16 to 0.48)	7 (6 to 11)

Omeprazole 40 mg reduces dyspepsia more effectively than omeprazole 20 mg.

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
recently-healed peptic ulcer or erosions on regular NSAIDs a	omeprazole 40 mg	omeprazole 20 mg	moderate to severe symptoms of dyspepsia at 8 weeks	11%	45% (6% to 68%)	20 (11 to 160)

Long-term NSAIDS: regular proton-pump inhibitors lead to less GI damage and fewer recurrent bleeds than eradication therapy 

Patient	Treatment	Comparison	Outcome	CER	RRI (95% CI)	NNH (95% CI)
recent upper GI bleed due to ulcers or erosions, on long-term naproxen a	single course of H.pylori eradication therapy	regular omeprazole	recurrent upper GI bleeding at 6 months	4%	330% (29% to 1400%)	8 (4 to 27)
history of peptic ulcer disease on long-term NSAIDs a	single course of H.pylori eradication therapy	regular pantoprazole	severe gastrointestinal damage on endoscopy at 4 weels	0%		4 (2 to 7)