NSAIDs相关性溃疡的防治策略课件.ppt

* 12. Probability of NSAIDs-associated gastroduodenal damage is related to gastric acidity The pH dependence of NSAID-mediated mucosal damage has also been demonstrated in healthy individuals during a study in which naproxen was given to 37 volunteers for 6 days, either alone or in combination with a gastric antisecretory agent. The study showed that the individuals who benefited from partial inhibition of gastric acid secretion had a significantly lower incidence of gastric pathology (53%) than those whose gastric acidity had remained unchecked (89%; p=0.029). The importance of pH in predicting the extent of damage was shown by the individuals’ integrated gastric acidity. This parameter takes into account the concentration of H+ ions (protons) over the entire 24-hour period, with a higher value equalling higher acidity. Thus, good acid control (low integrated gastric acidity) was predictive of a lower probability of NSAID-associated gastric damage; high acidity was predictive of the development of gastroduodenal pathology.11 3641 3402 3180 2806 1073 533 N=4047 N=4029 3644 3389 3163 2796 1071 513 # at Risk: Rofecoxib Naproxen 罗非希布 萘普生 随访月数 0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 2 4 6 8 10 12 出现胃肠溃疡的时间 All Patients Randomized 累计发病率 (%) Bombardier et al. N Engl J Med. 2000. VIGOR研究 COX-2抑制剂致溃疡作用明显下降 减少NSAIDs相关溃疡的策略 止痛治疗：用非NSAIDs止痛药,选用选择性COX-2抑制剂 停用抗血小板药物，换用其他抗血小板药物 尽可能小剂量 根除幽门螺杆菌 联合抗溃疡药物 质子泵阻滞剂 米索前列醇 氯吡格雷 氯吡格雷75mg与阿司匹林325mg相比 氯吡格雷组胃肠道出血的发生率低于阿司匹林组 氯吡格雷组胃肠道出血患者住院率低于阿司匹林组 氯比格雷是否存在自己独立的胃肠道损伤作用 是否通过抗血小板作用只引起已损伤粘膜的出血 ？ PPI制剂降低氯吡格雷的抗血小板活性 氯吡格雷合用PPI制剂使氯吡格雷的作用降低 PPI制剂抑制氯吡格雷代谢酶CYP2C19 Gilard M et al. J Am Coll Cardiol 2008 奥美拉唑 泮托拉唑、雷贝拉唑 Jolanta M.et al. Am Heart Journal， 2009 减少NSAIDs相关溃疡的策略 止痛治疗：用非NSAIDs止痛药,选用选择性COX-2抑制剂 停用抗血小板药物，换用其他抗血小板药物 尽可能小剂量 根除幽门螺杆菌 联合抗溃疡药物 质子泵阻滞剂 米索前列醇 Plachetka et al. American Gastroenterological Association Meeting 2003. 胃酸与NSAIDs所致上消化道损害具有相关性 0 20 40 60 80