Peptic ulcer disease is a frequent pathology; although the incidence has decreased in recent years, it continues to be an important cause of morbidity and mortality associated with high healthcare costs. The most important risk factors are Helicobacter pylori(H. pylori) infection and the use of non-steroidal anti-inflammatory drugs. Most patients with peptic ulcer disease remain asymptomatic, with dyspepsia being the most frequent and often characteristic symptom. It can also debut with complications such as upper gastrointestinal bleeding, perforation or stenosis. The diagnostic technique of choice is upper gastrointestinal endoscopy. Treatment with proton pump inhibitors, eradication of H. pylori and avoiding the use of non-steroidal anti-inflammatory drugs are the basis of treatment. However, prevention is the best strategy, it includes an adequate indication of proton pump inhibitors, investigation and treatment of H. pylori, avoiding non-steroidal anti-inflammatory drugs or using those that are less gastrolesive.

Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy). NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.

BACKGROUND: Chronic spontaneous urticaria is a prevalent and difficult-to-treat condition that has a very negative impact on patient quality of life.
OBJECTIVE: To describe the epidemiological and clinical characteristics of patients presenting with chronic spontaneous urticaria and the response to treatment administered according to the EAACI/GA(2)LEN/EDF/WAO consensus guideline.
METHODS: Descriptive cross-sectional study of all the patients with chronic spontaneous urticaria who consulted a skin allergy unit in the dermatology department of a tertiary hospital in Spain between July 2011 and July 2015.
RESULTS: The study included 100 patients with chronic spontaneous urticaria; inducible urticaria was present in 43% of cases, and angioedema in 40%. On diagnosis, 53% of patients were taking nonsteroidal anti-inflammatory drugs. All patients were treated with second generation H1-antihistamines, but the standard dose was sufficient in only 18% of cases. Higher doses (up to 4 times the standard dose) achieved control of the urticaria in 74% of the patients studied. Higher doses of second generation H1-antihistamines were required to control the condition in patients with angioedema, and the presence of angioedema was associated with a lack of response to treatment with these drugs (OR, 6.1%; P<.001). One in 4 patients failed to respond to second generation H1-antihistamines and required treatment with omalizumab or ciclosporin to control their condition.
CONCLUSIONS: Doses of H1-antihistamines higher than the standard dose are required in most cases to achieve control of chronic spontaneous urticaria. Angioedema is associated with failure to respond to treatment with antihistamines. In refractory cases, control of the condition can be achieved with omalizumab or ciclosporin. Patients with chronic spontaneous urticaria do not generally avoid the use of nonsteroidal anti-inflammatory agents.

The main innovations of the latest meeting of the Gastroenterological Association (2016) concerning upper gastrointestinal bleeding from the clinician\'s perspective can be summarised as follows: a) The Glasgow-Blatchford scale has the best accuracy in predicting the need for surgical intervention and hospital mortality; b) Prognostic scales for non-variceal upper gastrointestinal bleeding are also useful for lower gastrointestinal bleeding; c) Preliminary data suggest that treatment with hemospray does not seem to be superior to current standard treatment in controlling active peptic ulcer bleeding; d) Either famotidine or a proton pump inhibitor may be effective in preventing haemorrhagic recurrence in patients taking aspirin, but this finding needs to be confirmed in further studies; e) There was confirmation of the need to re-introduce antiplatelet therapy as early as possible in patients with antiplatelet-associated gastrointestinal bleeding in order to prevent cardiovascular mortality; f) Routine clinical practice suggests that gastrointestinal or cardiovascular complications with celecoxib or traditional NSAIDs are very low; g) Dabigatran is associated with an increased incidence of gastrointestinal bleeding compared with apixaban or warfarin. At least half of the episodes are located in the lower gastrointestinal tract; h) Implant devices for external ventricular circulatory support are associated with early gastrointestinal bleeding in up to one third of patients; the bleeding is often secondary to arteriovenous malformations.

OBJECTIVE: The chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause complications in the gastrointestinal tract. The use of proton pump inhibitors (PPIs) is recommended in high-risk patients to prevent them.
OBJECTIVE: The aim of this article was to evaluate the gastroprotection measures taken in persons with chronic NSAID use.
METHODS: A descriptive cross-sectional study was conducted. The clinical records were reviewed of patients seen as outpatients at the Rheumatology Department over a 4-month period, choosing those with chronic NSAID use, and intentionally looking for gastroprotection measures according to the recommendations published by the American College of Gastroenterology.
RESULTS: A total of 417 patients (347 women; mean age: 48.12±14.2 years) were included. The most frequent diagnosis was rheumatoid arthritis (65%). Nine patients (2.1%) had a history of peptic ulcer, 48 (11.5%) patients were 65 years of age or older, 26 (6.2%) patients took NSAIDs and aspirin, and 130 (31.2%) took NSAIDs with steroids. Tests for Helicobacter pylori infection were done in just 53 cases, and there were positive results in only 9 (16%). Some risk for gastrointestinal toxicity was established in 211 cases and only 65 (30.8%) received gastroprotection. In contrast, 31 (15%) patients received gastroprotection when there was no indication for it.
CONCLUSIONS: Prophylaxis with PPIs in chronic NSAID users was inadequately employed. It was not prescribed in the majority of patients (69.2%) and it was used with no justification in others (15%).

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most numerous category of drugs sharing the same mechanism of action and therapeutic activities (anti-inflammatory, analgesic and anti-pyretic). Despite having similar efficacy for pain relieve, the different available NSAIDs show variability in its safety profile. The risk of gastrointestinal and cardiovascular complications varies depending on the dose of NSAID and also the presence of different risk factors. It is necessary, therefore, an individualized case assessment before establishing the indication of the best NSAID for each patient, taking account of the best gastroprotection strategy. Improved prescription and enhanced treatment adherence are central objectives to reduce NSAID-related complications. A recent consensus of the Spanish Association of Gastroenterology and the Spanish societies of Cardiology and Rheumatology intends to promote the rational use of NSAIDs according to new recent studies. This review provides additional aspects to facilitate the optimal decision-making process in the routine use of these drugs in clinical practice.

In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage. The need for urgent endoscopy before 6-12 h after the onset of upper gastrointestinal bleeding episode may be beneficial in patients with hemodynamic instability and high risk for comorbidity. It is confirmed that in Western but not in Japanese populations, gastrointestinal bleeding episodes admitted to hospital during weekend days are associated with a worse prognosis associated with delays in the clinical management of the events. The strategy of a restrictive policy on blood transfusions during an upper GI bleeding event has been challenged. Several studies have shown the benefit of identifying the bleeding vessel in non varicose underlying gastric lesions by Doppler ultrasound which allows direct endoscopic therapy in the patient with upper GI bleeding. Finally, it has been reported that lower gastrointestinal bleeding diverticula band ligation or hemoclipping are both safe and have the same long-term outcomes.

OBJECTIVE: The aim of this study was to quantify and describe the prescription profile, as well as to assess the adequacy of treatment with non-steroidal anti-inflammatory drugs (NSAIDs) in the diabetic population of a health district.
METHODS: This is a descriptive, cross-sectional study aimed at a target population of 2,795 diabetic patients. Data were collected from the computerised clinical records of a sample of 380 individuals. The adequacy of treatment was assessed using the recommendations proposed by the Spanish societies of Rheumatology, Cardiology and Gastroenterology.
RESULTS: More than one-quarter (28%) of the diabetic patients received treatment with NSAIDs. The most commonly used ones were ibuprofen, naproxen, and dexketoprofen, with a defined daily dose per 1,000 inhabitants per day of 35.3, 17.2, and 13.2, respectively. In patients with a history of chronic kidney disease and cardiovascular high risk, fewer NSAIDs were prescribed, while they were used most frequently in patients with a risk for gastrointestinal adverse events. The prescription was considered adequate in 46.5% of diabetic patients. The main causes of inappropriate use were the inadequate prescription of NSAIDs (25.2%), and the use of any NSAID other than naproxen (20.6%).
CONCLUSIONS: The most prescribed NSAIDs were those showing a low cardiovascular risk profile. Treatment with NSAIDs was inadequate in more than half of the patients. Risk factors for cardiovascular, and especially gastrointestinal, events must be considered in order to avoid its use when not indicated, as well as the use of any NSAIDs other than naproxen.

OBJECTIVE: A retrospective economic evaluation was performed on the restriction of the use of piroxicam in Spain, a non-steroidal anti-inflammatory drug, with a proven higher risk of serious gastrointestinal complications compared to other non-steroidal anti-inflammatory drugs with the objective of putting the relevance of these activities into context.
METHODS: A retrospective cost-effectiveness analysis and a budget impact analysis were performed. Costs and cases of serious gastrointestinal complications were compared in the non-intervention (use of piroxicam) and the intervention scenarios (use of other non-steroidal anti-inflammatory drugs). The cost of serious gastrointestinal complications was obtained from the Diagnosis Related Groups and the cost of non-steroidal anti-inflammatory drugs from usage data in the Spanish national health system. The risk of serious gastrointestinal complications was obtained from epidemiological studies.
RESULTS: The regulatory intervention was the dominant option. In that sense, 0.81 euros per treated patient were saved, 2.75 cases of serious gastrointestinal complications were avoided per 10,000 patients and 578,608 euros were saved in total in Spain in the first year following the intervention.
CONCLUSIONS: It is possible to perform complete economical evaluations on pharmacovigilance actions. The intervention performed by the Spanish Agency for Medicines and Medical Devices, AEMPS on piroxicam not only achieved the objective of preventing adverse drug reactions but also resulted in significant economical savings even under conservative assumptions.

REVIEẂS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery.
UNASSIGNED: In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery.
CONCLUSIONS: this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.