What is the treatment for a patient with Gastroesophageal Reflux Disease (GERD) and a history of gastritis who is taking naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID))?

Treatment of GERD in a Patient with Gastritis Taking Naproxen

For a patient with GERD and a history of gastritis who is taking naproxen, the first-line treatment is a proton pump inhibitor (PPI) once daily, with consideration of discontinuing naproxen if possible, as PPIs are more effective than other acid-suppressing medications for healing esophagitis and providing symptomatic relief. 1

Pharmacological Management

First-Line Therapy

1. Proton Pump Inhibitors (PPIs)

   • Standard dose PPI once daily (e.g., omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, or rabeprazole 20 mg) 1, 2
   • Take 30-60 minutes before a meal for optimal effect 1
   • Initial treatment duration: 4-8 weeks 1, 2

2. If inadequate response to once-daily PPI:

   • Increase to twice-daily dosing 1
   • Or switch to a more potent PPI (e.g., esomeprazole or rabeprazole) 1
   • Patients whose symptoms don't respond to twice-daily PPI therapy should be considered treatment failures 1

Alternative or Adjunctive Medications

1. Histamine-2 Receptor Antagonists (H2RAs)

   • Less effective than PPIs but more effective than placebo 1
   • Can be used for short-term or as-needed therapy 1
   • May be combined with antacids for rapid symptom relief 1

2. Antacids

   • Most rapidly acting agents for immediate symptom relief 1
   • Can be used on demand or combined with H2RAs or PPIs 1

3. NOT RECOMMENDED: Metoclopramide

   • Evidence shows it's ineffective or harms outweigh benefits 1

NSAID Management (Critical for this patient)

1. Consider discontinuing naproxen if possible

   • NSAIDs are a significant risk factor for both gastritis and GERD complications 3

2. If naproxen must be continued:

   • PPI therapy is strongly indicated as PPIs effectively decrease NSAID-associated ulcers and GI complications 3
   • Consider misoprostol as an alternative or adjunct (200 mcg four times daily), though it has more side effects like diarrhea 4, 3

Lifestyle Modifications

While broad lifestyle recommendations aren't strongly supported for all patients, targeted modifications based on specific symptoms are recommended 1:

1. For nighttime symptoms:

   • Elevate head of bed
   • Avoid meals within 3 hours of bedtime 1

2. For symptom triggers:

   • Avoid specific foods that consistently trigger symptoms (e.g., alcohol, coffee, spicy foods) 1

3. Weight management:

   • Weight loss if patient is overweight or obese 1

4. Stress management:

   • Incorporate stress-reducing activities like mindfulness 1

Monitoring and Follow-up

1. Reassess symptoms after 4-8 weeks of therapy 1

2. For long-term management:

   • Taper PPI to lowest effective dose when adequate response is achieved 1
   • Consider endoscopy if symptoms persist despite therapy 1
   • For patients requiring long-term PPI therapy, evaluate appropriateness and dosing within 12 months 1

Special Considerations for This Patient

1. Gastritis history:

   • PPIs are preferred over H2RAs for patients with gastritis 1
   • Full-dose PPI therapy (e.g., omeprazole 20 mg daily) is recommended 1

2. NSAID use (naproxen):

   • Once-daily PPI therapy significantly decreases NSAID-associated ulcers and GI complications 3
   • Consider H. pylori testing, as eradication may reduce risk of NSAID-associated ulcers 5

Common Pitfalls to Avoid

1. Inadequate acid suppression:

   • Standard-dose H2RAs are not effective at preventing gastric ulcers in NSAID users 3
   • Don't undertreat - PPIs are more effective than H2RAs for GERD with concurrent NSAID use 1, 3

2. Overreliance on lifestyle modifications alone:

   • While helpful, lifestyle changes without acid suppression are insufficient for most patients with GERD and NSAID use 1

3. Failure to address NSAID use:

   • Not addressing the NSAID component significantly reduces treatment effectiveness 3

4. Inappropriate use of metoclopramide:

   • Evidence shows it's ineffective or harmful for GERD treatment 1