Serious morbidity associated with misuse of over-the-counter codeine–ibuprofen analgesics

To the Editor: The potential upper gastrointestinal morbidity associated with non-steroidal anti-inflammatory drug (NSAID) misuse is well known.1,2 Recently, Frei and colleagues3 provided an overview of the morbidity and patient characteristics relating to opioid–NSAID misuse; however, they did not identify those patients with NSAID enteropathy (NE). NE is thought to occur via NSAID-induced reduction of endogenous prostaglandin via inhibition of both cyclooxygenase (COX)-1 and COX-2. The result is altered mucosal integrity, which thereby allows exposure to noxious luminal contents leading to inflammation, erosion and ulcers.1 We underscore the importance of identifying this group of patients presenting with anaemia, hypoalbuminaemia, weight loss or abdominal pain that relates to NE.