What is the treatment for Non-Steroidal Anti-Inflammatory Drug (NSAID) induced gastric ulcer?

From the Guidelines

To treat an NSAID-induced gastric ulcer, the primary medication treatment is a proton pump inhibitor (PPI) such as omeprazole 20-40mg daily, pantoprazole 40mg daily, or esomeprazole 40mg daily for 4-8 weeks, as this has been shown to be effective in reducing stomach acid production and allowing the ulcer to heal 1. The first step is to discontinue the offending NSAID if possible. If H. pylori infection is present (which should be tested for), triple therapy is recommended: a PPI plus two antibiotics (typically amoxicillin 1g twice daily and clarithromycin 500mg twice daily) for 10-14 days. For pain management while the ulcer heals, acetaminophen is preferred over NSAIDs. Antacids can provide temporary symptom relief but don't heal ulcers. Patients should avoid alcohol, smoking, and spicy foods during healing. Protective medications like misoprostol or switching to a COX-2 selective NSAID with a PPI may be considered if continued NSAID therapy is necessary, as the combination of a COX-2 inhibitor with a PPI was associated with the greatest risk reduction for upper gastrointestinal complications 1. Some key points to consider when treating NSAID-induced gastric ulcers include:

• Discontinuing the offending NSAID if possible
• Using a PPI as the primary medication treatment
• Testing for H. pylori infection and treating with triple therapy if present
• Avoiding alcohol, smoking, and spicy foods during healing
• Considering protective medications like misoprostol or switching to a COX-2 selective NSAID with a PPI if continued NSAID therapy is necessary. PPIs work by blocking the hydrogen-potassium ATPase enzyme system in the stomach, effectively shutting down acid production by the parietal cells, creating an environment conducive to ulcer healing 1. It's also important to note that the protection afforded by prescription of gastroprotective agents will have some limits, and poor compliance may render them less useful 1. Overall, the goal of treatment is to reduce morbidity, mortality, and improve quality of life for patients with NSAID-induced gastric ulcers.

From the FDA Drug Label

Misoprostol tablets are indicated for reducing the risk of NSAID (nonsteroidal anti-inflammatory drugs, including aspirin)–induced gastric ulcers in patients at high risk of complications from gastric ulcer, e.g., the elderly and patients with concomitant debilitating disease, as well as patients at high risk of developing gastric ulceration, such as patients with a history of ulcer. Misoprostol should be taken for the duration of NSAID therapy. In a series of small short-term (about 1 week) placebo-controlled studies in healthy human volunteers, doses of misoprostol were evaluated for their ability to reduce the risk of NSAID-induced mucosal injury. Two 12-week, randomized, double-blind trials in osteoarthritic patients who had gastrointestinal symptoms but no ulcer on endoscopy while taking an NSAID compared the ability of 200 mcg of misoprostol, 100 mcg of misoprostol, and placebo to reduce the risk of gastric ulcer (GU) formation

To treat NSAID-induced gastric ulcers, misoprostol can be used. The recommended dose is 200 mcg taken for the duration of NSAID therapy. This has been shown to reduce the risk of gastric ulcers in patients at high risk of complications from gastric ulcer 2, 2.

• Key points:
  • Misoprostol should be taken with food to be effective topically.
  • The 200-mcg dose of misoprostol has been shown to cause a marked reduction in gastric ulcers.
  • Misoprostol does not reduce the risk of duodenal ulcers.
  • Women of childbearing potential using misoprostol should be told that they must not be pregnant when misoprostol therapy is initiated, and that they must use an effective contraception method while taking misoprostol 2.

From the Research

Treatment of NSAID-Induced Gastric Ulcers

• The treatment of NSAID-induced gastric ulcers involves the use of proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, and pantoprazole 3, 4, 5, 6.
• PPIs are effective in healing NSAID-induced gastric ulcers, even in the presence of continued NSAID treatment 3, 4, 5, 7.
• The use of PPIs is recommended over histamine H2 receptor antagonists (H2 antagonists) and misoprostol due to their superior efficacy and tolerability 3, 4, 5.
• The dosage of PPIs for the treatment of NSAID-induced gastric ulcers is typically 20-40 mg/day for 4-8 weeks 3, 4.

Prevention of NSAID-Induced Gastric Ulcers

• The prevention of NSAID-induced gastric ulcers involves the use of PPIs, H2 antagonists, and misoprostol 5.
• PPIs are effective in preventing NSAID-induced gastric ulcers, particularly in high-risk patients 5, 6.
• The use of COX-2 inhibitors and antisecretory drugs, particularly PPIs, can help minimize the risk of gastrointestinal complications in high-risk patients 6.

Mechanisms of Ulcer Healing

• The healing of NSAID-induced gastric ulcers by PPIs involves two mechanisms: acid-dependent reduction of pro-apoptotic signaling and acid-independent restoration of proliferating/repairing pathways 7.
• PPIs such as esomeprazole and lansoprazole can restore PCNA and Ki-67 expression, and normalize MDA levels, leading to the promotion of ulcer healing 7.