What about using COX-2 inhibitors instead? The COX-2 inhibitors have a lower risk of gastrointestinal tract injury.2 Gastric ulcers, GI bleeding, and complications from ulcers have been shown to be less common with COX-2 NSAIDs compared with nonselective NSAIDs.5 A review of the literature suggests that for patients with previous GI bleeding, COX-2 inhibitors are comparable to an NSAID paired with a PPI in preventing GI bleeding; pairing a COX-2 inhibitor with a PPI, however, appears to provide the greatest defense.2,4
Consider preventive steps. Patients at risk for complications are likely to benefit from the simultaneous use of prophylactic agents with NSAID therapy. Risk factors for NSAID-related GI complications include: a previous GI event; older age; simultaneous use of anticoagulants, corticosteroids, or other NSAIDs (including low-dose aspirin); high-dose NSAID therapy; and chronic debilitating disorders (especially cardiovascular disease).6
Our patient improved with medical management
Our patient was evaluated by general surgery during his hospital admission, but because he was stable—with a healing duodenal perforation—we opted to manage him medically. We started him on esomeprazole (40 mg bid) along with ciprofloxacin (500 mg bid) and metronidazole (500 mg tid) for the microperforation of the duodenum. The patient was also scheduled for an outpatient endoscopic evaluation.