Non-steroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, are a useful family of therapeutics.1) An inhibitory effect of NSAIDs on cyclooxygenase (COX) activity is responsible for their anti-inflammatory actions because COX is an enzyme essential for the synthesis of prostaglandins (PGs), such as PGE 2 , which have a strong capacity to induce inflammation. On the other hand, NSAID use is associated with gastrointestinal complications. [2][3][4] In 1991, two subtypes of COX, COX-1 and COX-2, which are responsible for the majority of COX activity at the gastrointestinal mucosa and in tissues with inflammation, respectively, were identified. 5,6) Since PGE 2 has a strong protective effect on the gastrointestinal mucosa, it is reasonable to speculate that selective COX-2 inhibitors maintain anti-inflammatory activity without gastrointestinal side-effects. In fact, a greatly reduced incidence of gastroduodenal lesions has been reported for selective COX-2 inhibitors (such as celecoxib and rofecoxib).7-9) However, a recently raised issue concerning the use of selective COX-2 inhibitors is their potential risk for cardiovascular thrombotic events. 10,11) This may be due to the fact that prostacyclin, a potent antiaggregator of platelets and a vasodilator, is mainly produced by COX-2 in vascular endothelial cells, while thromboxane A 2 , a potent aggregator of platelets and a vasoconstrictor, is mainly produced by COX-1 in platelets. [12][13][14] Because of this concern, rofecoxib was withdrawn from the worldwide market. Therefore, NSAIDs exhibiting gastrointestinal safety, other than selective COX-2 inhibitors, are clinically important.The inhibition of COX by NSAIDs is not the sole explanation for the gastrointestinal side-effects of NSAIDs.15) We have recently demonstrated that NSAIDs induce necrosis and apoptosis in cultured gastric mucosal cells and at gastric mucosa in a manner independent of COX inhibition. [16][17][18][19][20] We clearly showed that the primary target of NSAIDs for induction of necrosis and apoptosis is cytoplasmic membranes. 16,18) As for the molecular mechanism governing this apoptosis, we have proposed the following pathway. Permeabilization of cytoplasmic membranes by NSAIDs stimulates Ca 2ϩ influx and increases intracellular Ca 2ϩ levels, which in turn induces the endoplasmic reticulum (ER) stress response. 16,21,22) In this response, an apoptosis-inducing transcription factor, CCAAT/enhancer-binding protein (C/EBP) homologous transcription factor (CHOP), is induced and CHOP induces expression of p53 up-regulated modulator of apoptosis (PUMA) and resulting translocation and activation of Bax, mitochondrial dysfunction, activation of caspases and apoptosis.17,23) Furthermore, we have suggested that both COX inhibition and gastric mucosal cell death are required for the formation of NSAID-induced gastric lesions in vivo. 20,24) Loxoprofen has been used clinically for a long time as a standard NSAID in Japan, and clinical studies have suggested that it is safer than other NSAIDs, s...