What is the initial step in managing a patient with a duodenal ulcer and a history of chronic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) use?

Initial Management of NSAID-Induced Duodenal Ulcer

The correct answer is C: Start a proton pump inhibitor (PPI) immediately. This is the most appropriate initial pharmacologic intervention for a patient presenting with symptomatic duodenal ulcer in the setting of chronic NSAID use.

Rationale for PPI as First-Line Treatment

PPIs are the most effective agents for healing NSAID-associated duodenal ulcers and should be initiated immediately upon diagnosis. 1, 2, 3

• Lansoprazole 30 mg daily heals 79% of NSAID-associated gastric ulcers at 8 weeks, significantly superior to other agents 2
• Omeprazole demonstrates 100% gastric ulcer healing at 8 weeks versus 82% with sucralfate in patients continuing NSAIDs 4
• PPIs are superior to H2-receptor antagonists, misoprostol, and sucralfate for both healing and symptom relief in NSAID-induced ulcers 3, 5

Why Other Options Are Incorrect

Option A (Diet changes and OTC antacids): Inadequate

• Antacids alone do not heal peptic ulcers and provide only temporary symptomatic relief 1
• This approach fails to address the underlying mucosal injury and acid-mediated damage 3

Option B (Treat H. pylori first): Premature

• While H. pylori testing should be performed, it is not the immediate first step before initiating acid suppression 6, 1
• PPI therapy should begin immediately for symptom control and ulcer healing, with H. pylori eradication added if testing is positive 1
• H. pylori eradication alone is insufficient in NSAID users and requires co-therapy with gastroprotective treatment 6

Option D (Surgery): Not indicated

• Surgery is reserved for complications such as perforation, bleeding refractory to endoscopic treatment, or gastric outlet obstruction 1
• This patient has uncomplicated duodenal ulcer without alarm features requiring surgical intervention 1

Complete Management Algorithm

Immediate Actions (First 24-48 hours):

1. Start PPI therapy: Omeprazole 20-40 mg daily or lansoprazole 30 mg daily 2, 3
2. Discontinue NSAIDs immediately if possible 6, 1
3. If NSAIDs must be continued, maintain PPI co-therapy throughout treatment 6, 1

Short-term Management (First 4-8 weeks):

• Continue PPI for 4-8 weeks to achieve complete ulcer healing 1, 2
• Test for H. pylori infection during this period 6, 1
• If H. pylori positive, initiate triple therapy: PPI + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 1, 2

Long-term Prevention:

• If NSAIDs cannot be discontinued, continue PPI indefinitely for gastroprotection 6, 1
• Consider switching to COX-2 selective inhibitor plus PPI in high-risk patients 6
• After successful H. pylori eradication, maintenance PPI may not be necessary unless NSAIDs are continued 1

Critical Pitfalls to Avoid

• H2-receptor antagonists are inadequate for NSAID-associated gastric ulcers, protecting only against duodenal ulcers 6, 1
• Standard-dose H2-antagonists do not prevent gastric ulcers; double doses are required for both gastric and duodenal protection 1
• Misoprostol, while effective, causes significant diarrhea and GI intolerance limiting its use 1, 7
• Overlooking alarm symptoms (hematemesis, melena, significant weight loss, dysphagia) that require urgent endoscopic evaluation 1
• Poor compliance with gastroprotective agents increases risk of NSAID-induced complications 4-6 fold 1

Risk Stratification Context

This patient has moderate-to-high risk for GI complications based on: 6

• Chronic NSAID use (established risk factor)
• Symptomatic presentation with confirmed ulcer on endoscopy
• Post-prandial pain suggesting active disease

For moderate-risk patients (1-2 risk factors), guidelines recommend either least ulcerogenic NSAID plus PPI, or COX-2 inhibitor alone 6