Review Question - QID 101360

A patient in treatment for H. pylori infection likely suffers from peptic ulcer disease (PUD). Selective COX-2 inhibitors such as celecoxib are preferred in patients with PUD due to their lower incidence of GI side effects.

NSAIDs inhibit cyclooxygenase (COX) enzymes and thereby decrease the formation of prostaglandins and thromboxanes. Most NSAIDS, including aspirin, are non-selective COX inhibitors. However, the side effects of GI irritation, ulceration, and bleeding are related to the inhibition of COX-1 specifically. Since COX-2 is preferentially expressed at sites of inflammation, selective COX-2 inhibitors, such as celecoxib, were developed to reduce the incidence of these side effects. As such, COX-2 inhibitors are recommended in patients with PUD.

Risser et al discuss NSAID prescribing precautions: "Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used, but have risks associated with their use, including significant upper gastrointestinal tract bleeding. Older persons, persons taking anticoagulants, and persons with a history of upper gastrointestinal tract bleeding associated with NSAIDs are at especially high risk. Although aspirin is cardioprotective, other NSAIDs can worsen congestive heart failure, can increase blood pressure, and are related to adverse cardiovascular events, such as myocardial infarction and ischemia."

Noble et al review the use of COX-2 inhibitors: "COX-2 inhibitors and traditional NSAIDs do not appear to differ significantly in their effectiveness in alleviating pain or inflammation. They have similar gastrointestinal side effects, including abdominal pain, dyspepsia and diarrhea. However, short-term studies show fewer gastrointestinal ulcers in patients treated with COX-2 inhibitors compared with traditional NSAIDs."

Illustration A is a flow diagram showing the interaction of COX-2 selective inhibitors and nonspecific NSAIDs on the metabolites of arachidonic acid.

Incorrect answers:
Answer 1: Aspirin is a non-selective NSAID that inhibits COX-1 and COX-2 by irreversible acetylation. It has well-known GI side effects and is not the preferred agent for patients with peptic ulcer disease.
Answer 2: Ibuprofen is a non-selective NSAID that has GI side effects.
Answer 3: Codeine is an opioid, not an NSAID.
Answer 4: Bismuth is an element found in the compound bismuth subsalicylate. Bismuth subsalicylate is given as part of some triple therapy regimens used to eradicate H. pylori infection.