40 million people worldwide rely on daily doses of NSAID to treat chronic pain. About 25% of these patients develop ulcers. This is related to significant mortality largely due to NSAID-related gastrointestinal bleeds. The risk of gastrointestinal side effects resulting from NSAID use increases with age - unfortunately so does the use of this class of analgesia. A number of strategies have therefore been adopted to overcome the gastrointestinal toxicity of NSAIDS. One strategy has involved the use of misoprostol as a means of protecting against bleeding. This approach has been exploited in the treatment of arthritis where misoprostol and NSAID is given as a combined therapy, Arthrotec. More generally misoprostol is given independently as Cytotec as an adjunct to NSAID treatment irrespective of the nature of the pain that is being treated. However protection is often limited by the side-effects related to the use of this prostaglandin derivative. An alternative approach could involve the use of proton pump inhibitors. Thus the efficacy/side-effect profile of misoprostol has recently been compared with that of lansoprazole. Patients receiving lansoprazole remained free from gastric ulcer for a shorter time than those who received misoprostol. After 12 weeks of treatment 82% of patient treated with lansoprazole remained free of ulcers compared to 93% of patients treated with misoprostol. Despite the efficacy related advantage of misoprostol, a significantly higher proportion of patients in the misoprostol group withdrew from the study because of treatment-related adverse events. When the impact of withdrawals on ulcer development was considered, therapy was successful for 69% for each of the active treatment groups. This suggests that proton pump inhibition could offer an alternative to misoprostol in the treatment of NSAID-related GI injury. As a further alternative, Taiwanese researchers have developed a new and improved formulation of misoprostol (click here for free access to our recent dossier overviewing this technology) with fewer side effects than currently available formulation. Adoption of this technology may protect the misoprostol market from erosion by alternative treatments such as proton pump inhibitors or through the use of COX-2 inhibitors.

Ulcer prevention in long-term users of nonsteroidal anti-inflammatory drugs: results of a double-blind, randomized, multicenter, active- and placebo-controlled study of misoprostol vs lansoprazole

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