NSAIDs, stomach ulcers and gastrointestinal bleeding

The stomach is constantly bathed in acid, and it survives because its lining makes a protective mucus layer. Prostaglandins help maintain that layer and the blood supply beneath it. NSAIDs relieve pain by blocking prostaglandin production, and the same action thins the stomach lining protection. Over days or weeks this can lead to inflammation, erosions and a true ulcer.

This is a medicine-induced problem, and the NHS names regular NSAID use, alongside Helicobacter pylori infection, as one of the two main causes of stomach ulcers. The risk of serious side effects is higher at a high dose or with long-term use, according to the NHS page for ibuprofen. Ulcers caused this way can bleed slowly, so a person becomes anaemic and tired, or they can bleed suddenly and heavily.

Indigestion and stomach aches are among the common side effects listed for ibuprofen, and they are easy to dismiss. A stomach ulcer typically causes burning upper abdominal pain that may be worse at night, along with bloating and nausea. Some NSAID-related ulcers cause very little pain before they bleed, which is why the warning signs of bleeding deserve attention in their own right.

The NHS tells anyone with a current or past stomach ulcer to check before taking ibuprofen. It also lists bleeding or clotting problems, asthma, heart, liver or kidney conditions, and previous allergic reactions to NSAIDs among the reasons to ask first. Combining medicines matters too: the NHS names anticoagulants such as warfarin, steroid medicines, antidepressants and blood pressure medicines as groups that can interact with ibuprofen.

Two NSAIDs together carry additional risk. The NHS advises not to take ibuprofen at the same time as naproxen or aspirin, because it increases the chance of serious side effects such as ulcers. Many people forget that over-the-counter cold remedies, gels with oral tablets and prescribed anti-inflammatories can all add up.

Older age and smoking are also associated with stomach ulcers. Heavy alcohol use adds to irritation; the NHS suggests avoiding a lot of alcohol while taking ibuprofen.

The MHRA has long said that gastrointestinal toxicity and cardiovascular toxicity are the two most important safety concerns for NSAIDs and COX-2 inhibitors. In its comparison, low-dose ibuprofen has the lowest gastrointestinal risk of the traditional NSAIDs, while piroxicam, ketoprofen and ketorolac were singled out for higher risk. COX-2 inhibitors (coxibs) generally cause less gastrointestinal harm than most NSAIDs, though the evidence for reducing the most clinically important risks with etoricoxib was described as weak.

The same MHRA review notes that proton pump inhibitors reduce the gastrointestinal risks of NSAIDs and may bring the risk down to a level similar to a coxib alone. NICE osteoarthritis guidance applies this: topical NSAIDs are offered first for knee osteoarthritis, and where an oral NSAID is chosen, a gastroprotective treatment such as a proton pump inhibitor should be offered while it is taken.

In practice this means the safest approach is the lowest effective dose for the shortest time, a topical product where it suits the joint, and a stomach-protecting tablet if oral treatment must continue.

If an ulcer is suspected the GP may arrange a breath, stool or blood test for H. pylori and sometimes a gastroscopy, a camera test of the food pipe and stomach. Finding H. pylori matters because infection and NSAIDs can both contribute, and treating the bacteria is part of healing.

Treatment usually involves stopping or changing the NSAID and a course of acid-reducing medicine. The NHS says treatment normally lasts from one week to two months depending on the cause, and that follow-up tests may be offered to confirm the ulcer has healed. Smoking cessation helps healing and lowers recurrence.

Someone who is bleeding is assessed in hospital under NICE guidance for acute upper gastrointestinal bleeding, which covers resuscitation, risk scoring and endoscopy. A person who has bled from an NSAID ulcer will usually be advised to avoid the offending painkiller in future.

Before long-term NSAID use, ask your prescriber to review your ulcer history, your other medicines and whether a stomach protector is needed. Ask whether paracetamol, topical products or non-drug approaches could do part of the work, though for some conditions NICE has moved away from routine paracetamol so the decision is individual.

Keep a single list of every painkiller you take, including over-the-counter tablets, aspirin taken for the heart and cold or flu products. Report suspected reactions through the MHRA Yellow Card scheme, and tell every clinician about any past ulcer or bleed.