Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
Saved on this device
!
Bleeding during NSAID treatment
Haematemesis, melaena, syncope or shock during NSAID therapy represents acute upper-GI bleeding until proved otherwise and requires hospital assessment rather than a routine gastroprotection review.
Action: Stop non-aspirin NSAIDs during the acute bleed, resuscitate, correct clinically important coagulopathy, arrange timely endoscopy and revisit the analgesic indication after haemostasis.
Synopsis
Estimate gastrointestinal and cardiovascular harm before starting an NSAID, remove avoidable exposure, prescribe effective gastroprotection for those who must continue, and review both benefit and toxicity.
Start with the pain diagnosis and non-drug measures; an NSAID without meaningful functional benefit creates risk without therapeutic justification.
Use the lowest effective NSAID dose for the shortest necessary time and avoid simultaneous prescribed and over-the-counter products.
NICE advises stopping the NSAID where possible when a peptic ulcer is diagnosed and treating with full-dose PPI or H2-receptor antagonist for eight weeks.
Key red flags
Previous peptic ulcer or upper-GI bleeding, age over 60, anticoagulation, antiplatelet therapy, corticosteroids and multiple NSAIDs materially increase ulcer or haemorrhage risk.
A PPI reduces upper-GI injury but does not prevent NSAID-related acute kidney injury, fluid retention, hypertension or cardiovascular thrombosis.
Identify all NSAIDs, aspirin, antithrombotics, corticosteroids and interacting drugs.
Ask explicitly about ibuprofen and combination products because electronic prescriptions omit non-prescribed exposure.
Worked reasoning
Worked case: prevention before prescribingProtect a patient who truly needs treatment
A 72-year-old with a previous uncomplicated gastric ulcer needs a short course of anti-inflammatory treatment for an acute crystal arthritis flare after other measures are considered unsuitable.
Confirm the inflammatory indication, reconcile aspirin and over-the-counter NSAIDs, check renal function and blood pressure, and recognise age plus previous ulcer as upper-GI risk.
Select the lowest effective anti-inflammatory dose for the shortest planned course and prescribe omeprazole 20 mg orally once daily during exposure rather than waiting for dyspepsia.
At the planned one-week review the flare has settled, renal function and haemoglobin are unchanged and no melaena or epigastric pain has occurred, so the NSAID is stopped rather than renewed automatically.
Verify that omeprazole duration is reviewed after NSAID cessation and that the patient understands to avoid duplicate over-the-counter ibuprofen or naproxen.
Key medicines
Omeprazole for NSAID-ulcer preventionFor an adult at risk of NSAID-associated gastric or duodenal ulcer, give omeprazole 20 mg orally once daily while the ulcerogenic exposure remains necessary, using the current 20 mg capsule SmPC. Review and stop unnecessary NSAID and PPI treatment rather than allowing either prescription to continue indefinitely. Administer the prevention capsule each morning with water and swallow it whole; chewing or crushing destroys the protected pellets.Exclude active ulcer or bleeding when symptoms, anaemia or melaena are present. In hepatic impairment the SmPC states 10–20 mg daily may be sufficient. Review the nelfinavir contraindication, clopidogrel interaction, acute interstitial nephritis, enteric infection and longer-term hypomagnesaemia, B12 deficiency and fracture risk. Protection is incomplete when multiple antithrombotic or ulcer risks coexist. No dose adjustment is required solely for renal impairment.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.