How to reduce gastritis symptoms while taking NSAID (Non-Steroidal Anti-Inflammatory Drug) for pain?

Reducing Gastritis Symptoms While Taking NSAIDs Three Times Daily

If you must continue the NSAID three times daily, add a proton pump inhibitor (PPI) as your first-line gastroprotective agent, as PPIs are superior to H2 antagonists and better tolerated than misoprostol for preventing NSAID-induced gastric injury. 1

Immediate Management Strategy

First Priority: Reassess NSAID Necessity

• Confirm the patient truly requires NSAID therapy rather than alternative analgesics 1
• Consider substituting acetaminophen (paracetamol) up to 4g daily as first-line therapy, which has a favorable gastrointestinal safety profile 1, 2
• If acetaminophen provides insufficient relief, consider adding co-codamol before escalating to NSAIDs 1

Second Priority: Optimize NSAID Selection and Dosing

• Switch to ibuprofen 1.2g daily (the lowest-risk NSAID) if not already prescribed 1
• Use the lowest effective dose for the shortest duration necessary 1, 3
• Consider reducing the current NSAID dose if adequate analgesia can be maintained 1

Gastroprotective Co-Therapy Options (Ranked by Evidence)

Option 1: Proton Pump Inhibitors (PREFERRED)

• PPIs (omeprazole 20-40mg daily) are as effective as misoprostol in healing and preventing NSAID-induced ulcers and are better tolerated 1
• PPIs effectively reduce dyspepsia symptoms and maintain ulcer healing even with ongoing NSAID use 4, 5
• Omeprazole has demonstrated superiority over ranitidine for gastric ulcer healing, particularly during concomitant NSAID therapy 6

Option 2: Misoprostol (If PPI Unavailable or Ineffective)

• Misoprostol reduces serious upper gastrointestinal complications with a number needed to treat of 264 over 6 months 1
• Major limitation: 5% of patients withdraw in the first month due to diarrhea and other side effects 1
• Consider only for high-risk patients (history of GI bleeding, multiple risk factors) where NSAID cannot be discontinued 1

Option 3: H2 Antagonists (LEAST EFFECTIVE)

• H2 antagonists (ranitidine 150mg twice daily) prevent duodenal ulcers during long-term NSAID use but NOT gastric ulcers 1, 5
• H2 antagonists have only a small impact on severe gastric symptoms, with unclear benefits over simple antacids 1
• Not recommended as primary gastroprotection for NSAID users 5

Risk Stratification and Tailored Approach

High-Risk Patients (Require Aggressive Gastroprotection)

High-risk features include: 1

• History of previous ulcer complications
• Age >70 years
• Concomitant use of aspirin, anticoagulants, or corticosteroids
• Multiple NSAIDs or high-dose NSAID therapy

For high-risk patients: Use a COX-2 selective NSAID PLUS a PPI, or avoid NSAIDs entirely 1

Moderate-Risk Patients (1-2 Risk Factors)

• Use lowest-risk NSAID (ibuprofen 1.2g daily) PLUS PPI or misoprostol 1

Low-Risk Patients (No Risk Factors)

• Use lowest effective dose of least ulcerogenic NSAID (ibuprofen) 1
• Consider PPI co-therapy if symptomatic gastritis develops 1

Additional Protective Measures

Timing of NSAID Administration

• Administer NSAIDs at the initiation of meals rather than after food 7
• Taking NSAIDs before or with food significantly reduces gastritis symptoms compared to after-food administration (6.45% vs 36.11% incidence) 7

Helicobacter pylori Considerations

• Test all patients requiring regular NSAID therapy for H. pylori, as infection increases risk of upper GI complications by 2-4 fold 1
• Eradicate H. pylori if present before initiating long-term NSAID therapy 1

Avoid Concurrent Gastric Irritants

• Discontinue aspirin and other NSAIDs if possible, as they increase intestinal permeability and gastritis risk 1
• Avoid alcohol and smoking, which compound gastric mucosal injury 8

Common Pitfalls to Avoid

• Do NOT use H2 antagonists as primary gastroprotection—they fail to prevent gastric ulcers 1, 5
• Do NOT assume symptom relief correlates with mucosal healing—up to 50% of NSAID users have endoscopic lesions without symptoms 8, 4
• Do NOT prescribe routine prophylaxis for all NSAID users—reserve for high-risk patients 1
• Do NOT combine multiple NSAIDs, as this dramatically increases adverse effects without additional benefit 3

Monitoring Requirements

• Review NSAID requirements at least every 6 months 1
• Encourage "as required" rather than scheduled dosing when possible 1
• If gastritis symptoms persist despite gastroprotection, consider endoscopy to rule out ulceration 1
• Monitor for signs of GI bleeding (melena, hematemesis, anemia) especially in high-risk patients 2