胃肠病有哪些症状 美国胃肠病学会（AGA）有关开据 NSAIDs处方的建议

非甾体类抗炎药的运用随同高发胃肠道并发症
专家组合意拟定引荐计划来减小风险

据美国胃肠病学会招集的多学科专家组介绍，非甾体类抗炎药给有适应症的患者供给了宽广的好处，可是保健部分在给患者开据这类药物前，需求细心考虑它的随同风险。胃肠道病变是运用非类固醇类抗炎药的最常见的不良反响，包含上消化道和下消化道的并发症。严峻的胃肠道并发症，如潜在的致命性出血性溃疡，年发作率为运用者的1－4％。

专家组的评论成果“关于拟定非甾体类抗炎药包含环氧化酶－2遏止剂和阿司匹林的运用计划评论会的一致”宣布在美国胃肠病学会出书的9月份的《临床胃肠病学与肝脏病学》杂志上。

“非甾体类抗炎药是全世界运用最广泛的药物，并且广泛的运用证明了它的成效和相对安全性” 据阿拉巴马大学伯明翰分校内科学教授，论文的首要作者C. Mel Wilcox博士介绍。“可是，曩昔尽管充沛认识了胃肠道并发症，而没有认识到其心脏风险，美国胃肠病学会招集洽谈会议来添加对运用该类药物的好处和胃肠道及心血管毒性的风险，然后改善对该类药物的运用。”

估量全世界每年耗费500亿阿司匹林片，其间美国大约6000万份处方开据了阿司匹林，并首要给晚年患者。这类药物对急、缓慢痛苦和骨骼肌肉炎症等方面有用。可是，非甾体类抗炎药的运用随同着严峻的风险，包含胃肠道、肾脏和心血管并发症，乃至包含心力衰竭和心肌梗死。

“咱们快乐地看到非甾体类抗炎药的胃肠道并发症和逝世现已从1992年开端下降，咱们以为这种情况归功于一下方面：小剂量运用非甾体类抗炎药；降低了幽门螺杆菌的盛行；添加了质子泵遏止剂的运用；以及引入对胃肠道更安全的非甾体类抗炎药的运用，如昔布类药物。” Wilcox博士说。“可是，保健部分和患者需求了解该类药物的相关风险来拟定非甾体类抗炎药的最佳运用计划。

专家组为保健部分拟定了当他们在决议是否给患者开非甾体类抗炎药时的以下主张：

点评医治的适应症和患者发作胃肠道和心血管并发症的潜在风险因子，并和患者评论心血管疾病的潜在风险因子。

对风险和好处进行剖析来衡量个别胃肠道和心血管风险后，开据低风险的药物。胃肠道出血发作风险大的患者需求运用胃肠道风险低的非甾体类抗炎药，例如非选择性非甾体类抗炎药；心血管事情发作风险大的患者需求承受环氧酶－2遏止剂医治；有已知心血管疾病或心血管病风险的患者需求承受小剂量阿司匹林。

约束所开非甾体类抗炎药的持续时间和剂量，以及咨询并主张患者进行非甾体类抗炎药的联合医治。

在运用非甾体类抗炎药医治前，先处理幽门螺杆菌的感染，致使不添加并发消化性溃疡的风险。

针对胃肠道并发症风险大的患者拟定胃肠维护计划，如运用米索前列醇或质子泵遏止剂。

“非甾体类抗炎药的运用随同低胃肠道并发症在确诊和医治上很重要，” Wilcox博士解说说。“更好地了解低胃肠道出血发作的风险和机理是削减非甾体类抗炎药的运用风险所需求的。”

在洽谈会议期间评论的药剂都是非类固醇类遏止炎症反响的药物，因此在学术上被以为是非甾体类抗炎药。非选择性的非甾体类抗炎药，包含布洛芬、依托度酸和萘丁美酮，它们比其他非甾体类抗炎药，例如舒林酸、吲哚美辛、吡罗昔康和酮咯酸对胃肠道具有更高的安全性。昔布类药物是选择性环氧化酶－2抑制剂。在规范剂量下，扑热息痛不是非甾体类抗炎药。

美国胃肠病学会专家组由胃肠病学、风湿病学、心脏病学和内科学医生组成，他们在小组评论后，以当时科研陈述为根底拟定了这个计划。

美国胃肠病学会举行的“关于非甾体类抗炎药的运用的洽谈会议”由TAP药品公司供给的一项无限教育基金赞助。与会者的财务开支发布包含在原稿内，在www.cghjournal.org.



Nonsteroidal anti-inflammatory drugs use associated with higher gastrointestinal complications
Consensus panel develops recommendations to minimize risks
Nonsteroidal anti-inflammatory drugs (NSAIDs) provide a broad range of benefits for patients who require their use, but health care providers need to carefully consider the associated risks before prescribing these drugs for their patients, according to a multi-disciplinary panel of experts convened by the AGA Institute. Gastrointestinal (GI) morbidities are the most common adverse events associated with NSAID use, including complications in both the upper- and lower-GI tracts; serious GI complications, such as potentially fatal bleeding ulcers, occur in one to four percent of NSAID users annually.

The findings of the panel, "Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin," were published in the September issue of Clinical Gastroenterology and Hepatology, published by the American Gastroenterological Association (AGA) Institute.

"NSAIDs are the most widely used medications in the world, and the broad use of these drugs confirms their effectiveness and relative safety," according to C. Mel Wilcox, MD, professor of medicine, University of Alabama at Birmingham, and lead author of the paper. "However, well-recognized GI complications and previously unrecognized cardiac risks have caused great concern about the use of these drugs among healthcare professionals. The AGA Institute convened the consensus conference to increase awareness about the benefits and the risks of GI and cardiovascular toxicities associated with these medications and to improve their use."

An estimated 50 billion aspirin tablets are consumed worldwide and approximately 60 million prescriptions are written for NSAIDs each year in the U.S., predominantly for older patients. These drugs are effective in acute and chronic treatment of painful and inflammatory musculoskeletal conditions, among others. However, NSAID use is associated with several risks including GI, renal and cardiovascular complications, including heart failure and myocardial infarction.

"We were pleased to note that both NSAID-associated GI complications and death have been decreasing since 1992, which we believe can be attributed to several factors: use of lower-dose NSAIDs; decreasing prevalence of H. pylori; increasing use of proton-pump inhibitors; and the introduction of NSAIDs with greater GI safety, such as coxibs," said Dr. Wilcox. "However, healthcare providers and patients need to be aware of the risks associated with these drugs to develop the best plan for using NSAID therapy."

The panel developed the following recommendations for healthcare providers to use when determining whether to prescribe NSAID treatment to their patients:

◎Review the treatment indication and potential patient risk factors, both for GI and cardiovascular complications, and discuss potential cardiovascular risk factor modifications with their patients.
◎Prescribe lower-risk agents after conducting a risk-benefit analysis to determine the GI versus cardiovascular risks for each individual. Patients who are at greater risk of GI bleeding should receive NSAIDs with lower GI risks, such as nsNSAIDs; patients with a greater risk of cardiovascular events should not receive COX-2 inhibitors; and patients with known or a high risk of cardiovascular disease should receive low-dose aspirin.
◎Limit the duration and dosage of the prescribed NSAID and ask about and advise their patients on combination NSAID therapy.
◎Treat patients with H. pylori infection prior to beginning NSAID therapy so as not to increase the risk of complicated ulcers.
◎Institute gastroprotection methods, such as misoprostol or proton pump inhibitors (PPIs), for patients at high-risk of GI complications.
"The association of NSAID use with lower-GI tract complications is important diagnostically and therapeutically," explained Dr. Wilcox. "A better understanding of risk factors for and mechanisms of lower-GI tract bleeding in NSAID users will be required to address risk reduction."

All agents discussed during the consensus conference were nonsteroidal, inhibit inflammation, and thus are technically considered NSAIDs. Nonselective NSAIDs include ibuprofen, etodolac and nabumetone, which may have superior GI safety than other nsNSAIDs, such as sulindac, indomethacin, piroxicam and ketorolac. Coxibs are selective NSAIDs. In standard doses, acetaminophen is not an NSAID.

The AGA Institute panel was comprised of physicians in gastroenterology, rheumatology, cardiology and internal medicine who developed the statement based on presentations of current scientific knowledge followed by group discussion.

The AGA Institute "Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents" was supported though an unrestricted educational grant from TAP Pharmaceutical Products Inc. Financial disclosures for conference participants are included in the manuscript at www.cghjournal.org.


修改：bluelove