Management of NSAID-Induced Duodenal Ulcer
Start a proton pump inhibitor (PPI) immediately at 20 mg once daily for 4 weeks, discontinue all NSAIDs if possible, and test for H. pylori with eradication therapy if positive. 1, 2
Immediate Actions
Discontinue NSAIDs immediately as they significantly increase the risk of ulcer recurrence and complications, even with PPI therapy. 1, 3 If NSAIDs cannot be stopped, you must continue PPI co-therapy indefinitely for gastroprotection. 1, 3
Initiate PPI therapy with omeprazole 20 mg once daily before meals for 4 weeks, which is the FDA-approved regimen for active duodenal ulcer treatment. 2 Most patients heal within 4 weeks, though some may require an additional 4 weeks. 2 PPIs are superior to H2-receptor antagonists for healing established NSAID-associated duodenal ulcers. 1, 4, 5
Essential H. pylori Testing
Test for H. pylori infection immediately, as it increases NSAID-related complications by 2-4 fold. 6, 3 All patients with duodenal ulcers should be tested, and if positive, eradication therapy is strongly recommended to prevent recurrent bleeding and ulcer recurrence. 1
If H. pylori is positive, initiate triple therapy: PPI (omeprazole 20 mg) + amoxicillin 1000 mg + clarithromycin 500 mg, all taken twice daily for 10-14 days. 1, 2 If an ulcer is present at therapy initiation, continue omeprazole 20 mg once daily for an additional 18 days for complete ulcer healing. 2
Risk Stratification and Long-Term Management
This patient has moderate-to-high risk given the history of NSAID use and now-documented duodenal ulcer. 6
After ulcer healing and successful H. pylori eradication (if present), maintenance PPI therapy is generally not necessary. 1 However, if NSAIDs must be continued, maintain PPI therapy indefinitely. 1, 3
For patients requiring continued NSAIDs after healing, consider switching to a COX-2 selective inhibitor (like celecoxib) combined with a PPI for high-risk patients. 6, 1
Why Not the Other Options?
H2-receptor antagonists (not listed but relevant) are inadequate as they only reduce duodenal ulcer risk at standard doses and do not protect against gastric ulcers. 6, 1 They are significantly less effective than PPIs for duodenal ulcer healing. 1, 7, 4
Elective surgical repair is only indicated for complications such as bleeding refractory to endoscopic treatment, perforation, or gastric outlet obstruction—none of which are present in this uncomplicated case. 1
Diet change alone has no established role in healing duodenal ulcers and would be inadequate management. 1
Critical Pitfalls to Avoid
- Never restart NSAIDs without gastroprotection, as poor compliance with PPI therapy increases the risk of NSAID-induced adverse events 4-6 fold. 3
- Do not use H2-receptor antagonists as first-line therapy—they are significantly less effective than PPIs. 1, 7
- Watch for alarm symptoms (hematemesis, melena, significant weight loss, dysphagia, recurrent vomiting) that require urgent endoscopic evaluation. 1, 3
- Avoid misoprostol as first-line due to significant gastrointestinal side effects that limit compliance, though it can be effective. 1, 8, 7