Nonsteroidal anti-inflammatory drugs are a fixture of musculoskeletal care. Patients with osteoarthritis, chronic low back pain, tendinopathy or a fresh sports injury often take them for weeks or months. Many add over-the-counter ibuprofen or naproxen on top of what was prescribed.

Attention stays on the joint. The stomach and intestines usually get noticed only once something has gone wrong. Physiotherapists, orthopedic clinicians, rheumatologists and manual therapists often see these patients more often than their prescriber does, which puts them in a good position to catch GI problems early.

Why NSAIDs injure the gut

NSAIDs relieve pain and inflammation by blocking cyclooxygenase (COX) enzymes. COX-1 also drives the prostaglandins that protect the gastric lining by maintaining mucus and bicarbonate secretion and mucosal blood flow. When those defenses drop, the stomach and duodenum become vulnerable to erosions, ulcers and bleeding.

Because the effect is systemic, enteric-coated tablets or suppositories reduce direct irritation but do not remove the risk. Taking the drug with food eases indigestion, not ulcer formation.

The most important clinical point is that many NSAID-related ulcers are silent. A large share of patients who present with a bleeding ulcer report no warning symptoms beforehand. The absence of heartburn or stomach pain is not reassurance.

Who is at highest risk

A prior ulcer or GI bleed is the strongest single predictor of another one. Risk also climbs with age over 65, high doses, and taking more than one NSAID at a time, which often happens when patients self-medicate with over-the-counter products.

Co-medications matter just as much. Anticoagulants, antiplatelet agents including low-dose aspirin, corticosteroids and SSRIs all compound the danger. So does Helicobacter pylori infection. A patient with two or more of these factors who takes NSAIDs most days deserves closer attention.

Don’t forget the small bowel

NSAID injury isn’t limited to the stomach. Capsule endoscopy studies show that small bowel erosions and ulcers are common in long-term users, a condition often called NSAID enteropathy.

These lesions rarely cause dramatic symptoms, but they can produce slow, hidden blood loss. Unexplained iron deficiency anemia in a chronic NSAID user should prompt a GI evaluation, even if an upper endoscopy comes back normal.

Red flags that warrant referral

Some findings call for same-day emergency assessment: black or tarry stools, vomiting blood or coffee-ground material, and dizziness or fainting alongside any of these.

Others warrant a prompt specialist referral. These include persistent upper abdominal pain or indigestion, new fatigue with pallor, iron deficiency anemia, unintentional weight loss, difficulty swallowing and early fullness after meals. Patients who need to keep taking NSAIDs despite a past ulcer or bleed also benefit from specialist input on how to do so safely.

Practical ways to reduce risk

Good pain control and GI safety are not mutually exclusive. Start with the lowest effective dose for the shortest time, and ask directly about over-the-counter use, which patients rarely volunteer. For knee and hand osteoarthritis, topical NSAIDs reach far lower blood levels and are a sensible first choice.

When a higher-risk patient needs oral therapy, guidelines support adding a proton pump inhibitor or using a COX-2 selective agent such as celecoxib, weighed against cardiovascular risk. Testing for and treating H. pylori before long-term NSAID use is recommended for patients with a history of ulcers.

Non-drug care belongs here too. Exercise therapy, weight management and manual therapy can reduce how much medication a patient needs in the first place.

Building a referral pathway

The best outcomes come from treating joint pain and GI safety as a shared responsibility. When a patient on regular NSAIDs reports warning signs, a timely evaluation by a gastroenterologist can identify ulcers, bleeding sources or H. pylori with endoscopy and set a safe long-term plan.

Access speed matters, because a silent ulcer can turn into an emergency within days. In Maryland, Gastro Center of Maryland offers GI appointments that are often available as soon as the next day, with on-site endoscopy centers, which makes it easier to act on a red flag rather than wait weeks.

One extra question at each visit, “How are your stomach and bowels doing on that medication?”, takes seconds and can prevent a hospital admission.

Related posts:

How Advanced Nursing Roles Are Improving Patient Care Outcomes 6 Best Remineralizing Toothpaste For Enamel Repair: Picks for Sensitive Teeth, Receding Gums, and Early Erosion How Healthcare Is Evolving to Meet Modern Patient Needs How Motion-Tracking Gadgets Improve Physical Therapy Accuracy Buy BPC-157 Peptide: Dosage, Side Effects, and How To Get BPC-157 Products in 2026 Best Peptides for Muscle Growth: A Research-Based Look at the Top Options

Stay updated, free articles. Join our Telegram channel

Join