Over-the-Counter and Prescription Management for Gastritis
For a patient with gastritis, start with over-the-counter antacids or H2-receptor antagonists (H2RAs) for symptom relief, but you should prescribe proton pump inhibitors (PPIs) or potassium-competitive acid blockers (P-CABs) for more robust acid suppression and mucosal healing, particularly if symptoms persist beyond initial OTC treatment. 1
Appropriate Over-the-Counter Options
The following OTC medications are appropriate for gastritis management:
Antacids: These remain first-line for mild, intermittent symptoms. They provide rapid symptom relief through direct acid neutralization and enhance gastric mucosal protection 1. Historically, antacids have been prescribed in 76-77% of gastritis consultations 2, 3.
H2-Receptor Antagonists (famotidine): Available OTC at lower doses, famotidine (20 mg/day) has demonstrated significant efficacy in attenuating epigastralgia, epigastric fullness, and heartburn while improving quality of life in patients with chronic symptomatic gastritis 4. This represents a step up from antacids when symptoms are more persistent.
When to Prescribe Prescription Therapy
You should prescribe prescription-strength therapy in the following situations:
1. Persistent or Moderate-to-Severe Symptoms
- PPIs provide more robust acid suppression than OTC options and promote faster mucosal healing 1
- P-CABs (newer agents) offer even more potent acid suppression and rapid symptom relief 1
2. H. pylori-Associated Gastritis
This is critical for preventing progression to peptic ulcer disease and gastric cancer:
- First-line treatment: Bismuth quadruple therapy for 14 days (bismuth + PPI + tetracycline + metronidazole) 5
- Alternative if bismuth unavailable: Concomitant 4-drug therapy 6
- H. pylori eradication cures gastritis and has potential to prevent gastric cancer 6
3. NSAID-Induced Gastritis
- If NSAID continuation is necessary: Co-prescribe a PPI as gastroprotective therapy 7
- Best prevention strategy: Switch to celecoxib (selective COX-2 inhibitor) at usual doses, which carries the lowest GI risk, combined with PPI in high-risk patients 7
- Critical caveat: Even OTC doses of NSAIDs (ibuprofen, naproxen) carry a relative risk of 3-4 for serious GI events—clinically significant despite being lower than prescription doses (RR 6-7) 8
- Consider acetaminophen/paracetamol first, as it is not associated with increased GI complications 8
Treatment Algorithm
Step 1: Determine the etiology
- Test for H. pylori if not already done (especially in high gastric cancer risk populations)
- Assess for NSAID use (including OTC formulations)
- Evaluate for autoimmune gastritis if indicated
Step 2: Initial management based on severity
- Mild, intermittent symptoms: OTC antacids
- Moderate symptoms or failed antacid trial: OTC or prescription H2RA (famotidine)
- Persistent/severe symptoms: Prescription PPI or P-CAB
Step 3: Address underlying cause
- H. pylori positive: Prescribe bismuth quadruple therapy × 14 days 5
- NSAID-related: Discontinue NSAID if possible, or switch to celecoxib + PPI 7
- Idiopathic/functional: Continue acid suppression with mucoprotective agents as needed 1
Important Caveats
Do not underestimate OTC NSAID risk: The widespread availability and underappreciation of true GI risk from OTC NSAIDs makes this a serious concern 8. Always inquire about OTC NSAID use.
Antibiotic resistance matters for H. pylori: Clarithromycin-based triple therapy has declining success rates due to resistance 6. Bismuth quadruple therapy avoids this problem and succeeds even with metronidazole resistance 6.
Aspirin interactions: If the patient takes aspirin, avoid ibuprofen/naproxen due to antiplatelet interference. Consider diclofenac or celecoxib instead, though careful individual assessment is needed in high CV risk patients 7.
Mucoprotective agents: These enhance mucosal regeneration, reduce inflammation, and mitigate oxidative stress—useful adjuncts to acid suppression 1.