What is the initial step in managing a female patient with a duodenal ulcer, chronic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) use for arthritis, and symptoms of nausea, vomiting, and abdominal pain that worsen after meals?

Initial Management: Start PPI Immediately

The initial step in managing this patient with an NSAID-induced duodenal ulcer is to start a proton pump inhibitor (PPI) immediately, specifically omeprazole 20 mg once daily, while discontinuing NSAIDs if possible. 1, 2, 3

Immediate Actions Required

Primary Treatment

• Initiate omeprazole 20 mg once daily immediately for ulcer healing and symptom control 1, 3
• The FDA-approved treatment duration is 4 weeks for active duodenal ulcer, with most patients healing within this timeframe 3
• Some patients may require an additional 4 weeks if healing is incomplete 3

NSAID Management

• Discontinue all NSAIDs immediately if possible, as they significantly increase the risk of ulcer recurrence and complications even with PPI therapy 1, 2
• If NSAIDs must be continued for arthritis management, maintain PPI co-therapy indefinitely for gastroprotection 1, 2
• Consider switching to acetaminophen as an alternative for pain relief, which does not cause gastric injury 2

Essential Testing: H. pylori

• Test for H. pylori infection immediately in all patients with duodenal ulcer, as it increases NSAID-related complications by 2-4 fold 1, 2
• If H. pylori is positive, initiate triple therapy eradication: PPI (omeprazole 20 mg) + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10-14 days 1, 3
• For patients with active ulcer at therapy initiation, continue omeprazole 20 mg once daily for an additional 18 days after completing triple therapy for complete ulcer healing 3

Why PPI is Superior to Other Options

PPI vs. Over-the-Counter Antacids

• PPIs are vastly superior to antacids for healing NSAID-induced duodenal ulcers, with healing rates of 75-82% at 4 weeks compared to 27% with placebo 3
• Antacids provide only symptomatic relief without addressing ulcer healing 4

PPI vs. H2-Receptor Antagonists

• PPIs heal duodenal ulcers significantly faster than H2-antagonists (82% vs 63% at 4 weeks with ranitidine) 3
• H2-antagonists are inadequate for NSAID-associated ulcers as they only protect against duodenal ulcers, not gastric ulcers 1

Why Not Surgery Initially

• Surgery is reserved for complications such as bleeding refractory to endoscopic treatment, perforation, or gastric outlet obstruction 1
• This patient has no indication for immediate surgical intervention based on the clinical presentation 1

Critical Pitfall to Avoid

Poor compliance with PPI therapy increases the risk of NSAID-induced adverse events 4-6 fold 2. Emphasize to the patient the importance of taking the PPI daily, even after symptoms resolve, for the full treatment duration.

Long-Term Strategy

• If NSAIDs cannot be discontinued, continue PPI indefinitely for gastroprotection 1, 2
• Consider switching to a COX-2 selective inhibitor (like celecoxib) combined with a PPI in high-risk patients requiring continued anti-inflammatory therapy 5, 2
• After successful H. pylori eradication (if positive), maintenance PPI therapy is generally not necessary unless NSAIDs must be continued 1

Alarm Symptoms Requiring Urgent Evaluation

Instruct the patient to seek immediate medical attention if any of the following develop 1, 2:

• Hematemesis (vomiting blood) 1
• Melena (black, tarry stools) 1
• Significant weight loss 1
• Difficulty swallowing (dysphagia) 1
• Recurrent vomiting suggesting gastric outlet obstruction 1