9 Ways to Reduce Your Risk of Bleeding Ulcers From NSAID Use

Bleeding typically occurs from the duodenum or stomach, but may also develop from the large intestine. While warning signs often occur, such as stomach discomfort or bloody/black stools, some patients—especially the elderly—may have no warning before they develop serious bleeding.

In addition to older age, other risk factors for this complication include multiple NSAID use (e.g., over-the-counter ibuprofen combined with prescription NSAIDs), blood thinners such as aspirin or coumadin (blood thinner), corticosteroids, smoking, excessive alcohol use, and prior history of stomach ulcers and gastrointestinal bleeding. In addition, some patients may have been exposed to the bacteria H. pylori at some time in their lives. This bacteria which is very common is associated with a higher risk of bleeding ulcers.

Fortunately, for those patients who need to take NSAIDs to treat their arthritis, there are ways to decrease the risk of ulcers and complications from ulcers such as gastrointestinal bleeding. We asked rheumatologist Scott J. Zashin, MD, who suggested these nine ways to decrease the risk of bleeding ulcers from NSAIDs.


Use an Ointment as an Alternative to Oral NSAIDs

Grimacing woman holding her aching stomach

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Consider alternative pain relievers such as Tylenol or tramadol. There are also topical treatments for localized pain including:

  • Thermacare patches (moist heat)
  • Ointments such as BenGay
  • Prescription NSAID gels or patches using diclofenac (Voltaren gel)

While diclofenac is an NSAID, application locally may decrease the level of NSAID in the blood and lower the risk of bleeding.

Oral NSAIDs may be an inappropriate first choice. There may be another way to effectively relieve pain, without the potential for severe side effects.


Adjust Your Dosage to Reduce Risk of Side Effects

It's optimal to take the lowest dosage of NSAID necessary to relieve your symptoms. By lowering the dosage to the lowest effective dose, you reduce the risk of side effects.

Another suggestion for you to consider—with your healthcare provider's approval—is to take your NSAID as needed as opposed to daily. By doing so, you would be reducing the risk of serious side effects.


Take a Safe Dose of NSAIDs

Quite simply: Avoid taking more than one NSAID at a time. That may sound like an obvious statement, but some patients may take two because of inadequate pain relief. They may not realize both drugs (for example, an over-the-counter NSAID and a prescription NSAID) are in the same therapeutic drug class. Taking two different NSAIDs is dangerous—it can increase the risk of undesirable side effects and serious adverse events.

Take your medication only as directed. If you have questions, don't hesitate to ask your healthcare provider or pharmacist.


Celebrex Capsules Reduce Ulcer Risk

You may consider choosing a specific NSAID, such as salsalate, which may have a lower risk of gastrointestinal bleeding compared to other NSAIDs.

There is also data that suggests Celebrex, a COX-2 inhibitor, may decrease the risk of bleeding from the large intestine. Talk to your healthcare provider to see if Celebrex would be a good option for you. It's worth noting, however, that Celebrex has been tied to heart risks. It's a balance—weighing risks and benefits.


Proton Pump Inhibitors Reduce Ulcer Risk

Combining an NSAID with a proton pump inhibitor (PPI) may decrease the risk of a stomach or duodenal ulcer. This is important for patients at increased risk. PPIs include Prilosec (available over-the-counter), Aciphex, Prevacid, Protonix, and Nexium. There is also a product that combines naproxen and Prevacid in one product.

Along with PPIs, misoprostol (Cytotec) may decrease the risk of ulcer. This product needs to be taken 4 times/day with food to achieve maximum protection, but some protection occurs when taken twice daily. This product is also available in combination with diclofenac. Misoprostol combined with diclofenac is marketed as Arthrotec. Misoprostol is contraindicated in women who are pregnant or could become pregnant because it can cause miscarriage.


Don't Ignore Medical Symptoms

Schedule regular consultations with your healthcare provider to go over any symptoms you may have. Have your bloodwork checked for any signs of bleeding. If you take NSAIDs, this should be part of your routine follow-ups with your healthcare provider.

By being proactive, it's possible to catch symptoms early and avoid an emergency situation. Since NSAIDs have known risks, both the patient and healthcare provider must be looking for signs of bleeding.


Get Tested for H. Pylori

Consider being tested for, and if positive, treated for H. pylori bacteria to decrease the risk of developing an ulcer. H. pylori can thrive in your stomach or the first part of your small intestine and have been associated with a higher risk of ulcers.

In fact, H. pylori infection is the most common cause of stomach ulcers, and it also results in inflammation of the stomach lining.


Take NSAIDs on a Full Stomach

It is not uncommon for patients taking NSAIDs to develop gastrointestinal symptoms. Taking the medication on a full stomach may improve tolerability.

Taking NSAIDs on an empty stomach increases the risk of developing ulcers—even if you are doing it now with no problem. The problem may be developing silently. To avoid the possibility, be sure to take NSAIDs with food.


Avoid Steroid Drugs With NSAIDs

Avoid steroid drugs (corticosteroids), if possible, in combination with NSAIDs. Some healthcare providers may combine a low dose of prednisone with an NSAID but consider adding a PPI if this is necessary.

Coumadin and NSAIDs also interact to increase the risk of ulcers or bleeding. Talk to your healthcare provider about reducing your risk of developing bleeding ulcers while taking NSAIDs. It's an important conversation.

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  1. Walker C. Are all oral COX-2 selective inhibitors the same? a consideration of celecoxib, etoricoxib, and diclofenac. International Journal of Rheumatology. 2018 Dec 9;2018. doi:10.1155/2018/1302835

Additional Reading
  • Answer provided by Scott J. Zashin, M.D., clinical assistant professor at University of Texas Southwestern Medical School, Division of Rheumatology, in Dallas, Texas. Dr. Zashin is also an attending physician at Presbyterian Hospitals of Dallas and Plano. He is a fellow of the American College of Physicians and the American College of Rheumatology and a member of the American Medical Association. Dr. Zashin is author of Arthritis Without Pain: The Miracle of Anti-TNF Blockers and co-author of Natural Arthritis Treatment.