What is the ongoing management for Non-Steroidal Anti-Inflammatory Drug (NSAID)-associated duodenal ulcer?

From the Guidelines

The ongoing management of NSAID-associated duodenal ulcers requires discontinuation of the offending NSAID when possible and initiation of proton pump inhibitor (PPI) therapy to promote ulcer healing and prevent recurrence. When managing NSAID-associated duodenal ulcers, several key considerations must be taken into account, including the need for endoscopy in patients presenting with dyspeptic symptoms who are taking NSAIDs regularly, as noted in the study by 1. Some key points to consider in the management of these ulcers include:

• Discontinuation of NSAID therapy if possible, as this can facilitate ulcer healing and reduce the risk of complications, as suggested by 1.
• Initiation of PPI therapy, such as omeprazole or pantoprazole, to reduce gastric acid production and promote ulcer healing, with evidence from 1 indicating that proton pump inhibition is superior for both healing and prophylaxis of NSAID-associated gastroduodenal damage.
• Assessment of risk factors for complications, including previous history of peptic ulcer disease, old age, glucocorticosteroid intake, and concomitant use of anticoagulants, as outlined in 1.
• Consideration of long-term acid suppression with a PPI for patients who must continue NSAID therapy due to medical necessity, as well as alternative strategies such as switching to a COX-2 selective inhibitor or using misoprostol as a gastroprotective agent, with guidance from 1 on the effectiveness of these approaches.
• Regular follow-up and endoscopic confirmation of healing for complicated ulcers, to ensure that the ulcer has healed and to reduce the risk of recurrence, as implied by the recommendations in 1.

From the FDA Drug Label

14.5 Healing of NSAID-Associated Gastric Ulcer In two U. S. and Canadian multi-center, double-blind, active-controlled studies in patients with endoscopically confirmed NSAID-associated gastric ulcer who continued their NSAID use, the percentage of patients healed after eight weeks was statistically significantly higher with 30 mg of lansoprazole than with the active control 14.6 Risk Reduction of NSAID-Associated Gastric Ulcer In one large U.S., multi-center, double-blind, placebo-and misoprostol-controlled (misoprostol blinded only to the endoscopist) study in patients who required chronic use of an NSAID and who had a history of an endoscopically documented gastric ulcer, the proportion of patients remaining free from gastric ulcer at four, eight, and 12 weeks was significantly higher with 15 or 30 mg of lansoprazole than placebo

The ongoing management for Non-Steroidal Anti-Inflammatory Drug (NSAID)-associated duodenal ulcer includes:

• Lansoprazole 15 mg or 30 mg daily to prevent the recurrence of duodenal ulcers and reduce the risk of NSAID-associated gastric ulcers 2
• Continued monitoring for symptoms of gastric ulcers, such as abdominal pain, and endoscopic evaluation to confirm healing and prevent recurrence
• Risk reduction strategies, such as using the lowest effective dose of NSAIDs and avoiding concomitant use of other medications that may increase the risk of gastric ulcers 2

From the Research

Ongoing Management for NSAID-Associated Duodenal Ulcer

The ongoing management for Non-Steroidal Anti-Inflammatory Drug (NSAID)-associated duodenal ulcer involves several strategies, including:

• Discontinuation of NSAIDs, if possible, to allow for ulcer healing 3, 4, 5
• Use of proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, and pantoprazole to heal and prevent ulcers 3, 6, 5
• Use of misoprostol, a prostaglandin analogue, to prevent NSAID-induced gastric and duodenal ulcers, although it may be less effective for duodenal ulcers and has a higher rate of adverse effects 3, 7, 4, 5
• Use of histamine H2 receptor antagonists (H2 antagonists) such as ranitidine, cimetidine, and famotidine to prevent NSAID-induced duodenal ulcers, but not gastric ulcers 4, 5
• Helicobacter pylori eradication in infected patients to decrease the risk of NSAID-associated lesions, although it is less effective than concomitant antisecretory treatment 3

Treatment Options

Treatment options for NSAID-associated duodenal ulcers include:

• PPIs, which are effective in healing ulcers and preventing recurrence 3, 6, 5
• Misoprostol, which is effective in preventing NSAID-induced gastric and duodenal ulcers, but may have adverse effects 3, 7, 4, 5
• H2 antagonists, which are useful in preventing NSAID-induced duodenal ulcers, but not gastric ulcers 4, 5
• Sucralfate, a barrier agent, which is not recommended as a prophylactic agent to prevent NSAID-induced gastropathy 5

Prevention Strategies

Prevention strategies for NSAID-associated duodenal ulcers include:

• Using the lowest possible dosage of NSAID 5
• Avoiding concomitant use of NSAIDs and corticosteroids 5
• Using a COX-2 selective NSAID 5
• Using preventive therapy such as PPIs or misoprostol 3, 6, 5