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Non-steroidal-anti-inflammatory drugs (NSAIDS) are among the most commonly prescribed medications. These drugs act on an enzyme called cyclooxygenase to block the productions of prostaglandins, substances that induce and aggravate inflammation.

Unfortunately, there are many prostaglandins and some of them are also responsible for several normal and important functions such as maintenance of the protective layer of the stomach and blood flow to the kidneys.

Therefore, while NSAIDS are very effective for relieving pain and inflammation, they also have unwanted and sometimes unexpected side effects including stomach and small intestinal ulcers, ulcers involving the large bowel, kidney damage, rashes, and liver function abnormalities.

[It has been suggested that selective cyclooxygenase-2 blockers (drugs that block the prostaglandin responsible for inflammation while not blocking the prostaglandins responsible for maintenance of normal stomach protection) might lower the risk of stomach-related events.]

Gastrointestinal side effects have been most commonly seen in patients with certain risk factors such as: age greater than 65, history of alcohol and cigarette use, history of steroid use, history of prior ulcers, and use of more than one NSAID at a time. Rheumatoid arthritis patients also seem to be at higher risk because they often have other disease conditions and are usually taking other medicines that can predispose to stomach problems.

Also, NSAIDS as a class have been demonstrated to confer a slight- but real- increase in the incidence of cardiovascular events such as heart attack and stroke. As a result, attempts have been made to try to minimize the risks of NSAIDS.

A recent Dutch study revealed that at least in their country, researchers have seen a decline in non-steroidal anti-inflammatory drug-induced gastrointestinal ulcers and related complications in patients with rheumatoid arthritis (RA).(Steen KSS, et al. Ann Rheum Dis. 2008;67:256-259).

This experience is similar to what has been demonstrated in the United States.

"This is most likely due to stricter adherence to guidelines for prevention of NSAID gastropathy (stomach side effects), and better treatment of rheumatoid arthritis," lead author, Dr. K. S. S. Steen of VU University Medical Center, Amsterdam, and colleagues suggest.

The study was conducted by sending questionnaires at 4-month intervals to all RA patients in Amsterdam, addressing medication use, heartburn, and symptomatic gastrointestinal events in the previous 4 months.

Based on at least one returned questionnaire from each of 2099 patients, the incidence of gastrointestinal events in high-risk patients using NSAIDs) was 1.2%, "which appears to be substantially lower than the 2.1% observed in 1997" in a similar population, the investigators said.

In 2003- the year the study was conducted- RA patients used fewer non-selective NSAIDs and more selective cyclooxygenase-2 drugs as compared to 1997.

Also, patients at risk for NSAID stomach problems used more acid suppressive agents, which have been shown to protect the stomach, in 2003 as compared with 1997.

The investigators concluded, "These reasons for the decline of gastrointestinal events in our study resemble the US data, despite socioeconomic, ethnic and RA treatment regime differences."

All medicines, if they are effective, have potential side effects. All medicines need to be weighed in terms of risk versus benefit. Patients need to be educated about the potential liabilities of their medications as well as the potential beneficial outcomes.