Gastrointestinal complications of antirheumatic drugs

Recently, there have been major changes in the understanding of the occurrence and pattern of adverse reactions in the gastrointestinal tract attributed to the antirheumatic drugs. Major changes among these include: (1) the increasing awareness of the multiorgan system toxicity of nonsteroidal antiinflammatory drugs (NSAIDs) and the disease-modifying antirheumatic drugs (DMARDs); (2) comorbidities from the occurrence of different rheumatic diseases especially cardiovascular disease; (3) the widespread use of aspirin and other antithrombotic drugs to control cardiovascular complications with consequent increase in the incidence of gastrointestinal (GI) complications; (4) the increasing use of antiacid secretory agents proton-pump inhibitors, H2-receptor antagonists alone or in fixed combinations with NSAIDs to reduce the occurrence of serious GI reactions (upper GI bleeding and ulceration), but with apparently profound consequences for the intestinal microbiome in the form of dysbiosis and intestinal inflammation; and (5) the changing pattern of use of NSAIDs and DMARDs especially in patients with rheumatoid arthritis (RA). The complications in the form of iatrogenic disease that occur in the GI tract from use of agents to protect the GI tract from NSAIDs are of particular concern.