NSAID (avoidance)
Place in Therapy
The existing literature suggests that NSAIDs should be avoided in patients with recurrent aphthous ulcers and should be ruled out as a drug-related cause particularly in patients who have recurrences of this condition (1). It is challenging to establish whether the use of NSAIDs provokes aphthous ulcers as primary literature is scant and case-control studies conducted employed very small sample sizes and wide confidence intervals (2). No randomized controlled trials have been conducted to date to evaluate this phenomenon (3). Another challenge is that there is currently no diagnostic criteria by which practitioners diagnose aphthous ulcers making reporting bias a commonly cited limitation in primary literature (1)(2)(3).
Reviews also provide conflicting information, with some stating NSAIDs may be used (4)(5), while other sources including tertiary references stating the exact opposite (6)(7)(8). Further investigation is required to establish a causal association. To err on the side of caution, they should not be recommended for patients with recurrent aphthous ulcers as this could be an aggravating factor. Importantly, asking patients about NSAID-use is important in the consideration of drug-related causes and etiology of this condition.
References:
1. Hasan AA, Ciancio S. Association between ingestion of Non-Steroidal Anti-Inflammatory Drugs and the emergence of Aphthous-like Ulcers. Journal of the International Academy of Periodontology 2009, 1(11):155-9
2. Boulingez S, Reix S, Bedane C et al. Role of drug exposure in aphthous ulcers: a case-control study. British Journal of Dermatology 2000, 43:1261-5
3. Boulingez S, Cornee-Leplat I, Bouyssou-Gauthier ML et al. Analysis of the literature about drug-induced aphthous ulcers. Ann Dermatol Venereol 2000, 127:155-8
4. Brocklehurst P,TickleM,GlennyAM, LewisMA, PembertonMN,Taylor J,WalshT,Riley P, Yates JM. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD005411. DOI: 10.1002/14651858.CD005411.pub2.
5. Eisenberg E. Diagnosis and treatment of recurrent aphthous stomatitis. Oral Maxillofacial Surg Clin N Am 15 (2003) 111 – 122.
6. Abdollahi M, Radfar M. A Review of Drug-Induced Oral Reactions. J Contemp Dent Practice 2003; 1(4): 10-31.
7. Chavan M, Jain H, Diwan N et al. Recurrent aphthous stomatitis: a review. Journal of Oral Pathology & Medicine (2012) 41:577-583.
8. Canadian Pharmacists Association. (2010). Aphthous Ulcers: Patient Self Care 2nd edition. Ontario, ON: Ottawa.
Reviews also provide conflicting information, with some stating NSAIDs may be used (4)(5), while other sources including tertiary references stating the exact opposite (6)(7)(8). Further investigation is required to establish a causal association. To err on the side of caution, they should not be recommended for patients with recurrent aphthous ulcers as this could be an aggravating factor. Importantly, asking patients about NSAID-use is important in the consideration of drug-related causes and etiology of this condition.
References:
1. Hasan AA, Ciancio S. Association between ingestion of Non-Steroidal Anti-Inflammatory Drugs and the emergence of Aphthous-like Ulcers. Journal of the International Academy of Periodontology 2009, 1(11):155-9
2. Boulingez S, Reix S, Bedane C et al. Role of drug exposure in aphthous ulcers: a case-control study. British Journal of Dermatology 2000, 43:1261-5
3. Boulingez S, Cornee-Leplat I, Bouyssou-Gauthier ML et al. Analysis of the literature about drug-induced aphthous ulcers. Ann Dermatol Venereol 2000, 127:155-8
4. Brocklehurst P,TickleM,GlennyAM, LewisMA, PembertonMN,Taylor J,WalshT,Riley P, Yates JM. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD005411. DOI: 10.1002/14651858.CD005411.pub2.
5. Eisenberg E. Diagnosis and treatment of recurrent aphthous stomatitis. Oral Maxillofacial Surg Clin N Am 15 (2003) 111 – 122.
6. Abdollahi M, Radfar M. A Review of Drug-Induced Oral Reactions. J Contemp Dent Practice 2003; 1(4): 10-31.
7. Chavan M, Jain H, Diwan N et al. Recurrent aphthous stomatitis: a review. Journal of Oral Pathology & Medicine (2012) 41:577-583.
8. Canadian Pharmacists Association. (2010). Aphthous Ulcers: Patient Self Care 2nd edition. Ontario, ON: Ottawa.