What is the recommended treatment for an older adult with a Type 2 gastric ulcer, likely caused by chronic Non-Steroidal Anti-Inflammatory Drug (NSAID) use or Helicobacter pylori (H. pylori) infection?

Treatment of Type 2 Gastric Ulcer in Older Adults

For an older adult with a Type 2 gastric ulcer, immediately discontinue all NSAIDs, initiate a proton pump inhibitor (PPI) at standard dosing (e.g., omeprazole 20-40 mg daily), and test for H. pylori with subsequent eradication therapy if positive. 1, 2

Immediate Management Steps

NSAID Discontinuation

• Stop all NSAIDs immediately as they significantly increase the risk of ulcer recurrence and complications, even with concurrent PPI therapy 3
• Substitute with acetaminophen for pain relief, which does not cause gastric injury 3
• If NSAIDs are absolutely necessary, use a COX-2 selective inhibitor (celecoxib) combined with a PPI for gastroprotection 1, 4

Acid Suppression Therapy

• Start a PPI immediately for ulcer healing—PPIs are superior to H2-receptor antagonists for healing NSAID-associated gastric ulcers 2
• Standard dosing: omeprazole 20-40 mg once daily or equivalent PPI 2, 3
• Continue treatment for a full 8 weeks to ensure complete healing 2, 3
• After healing, consider maintenance PPI therapy if NSAIDs must be continued indefinitely 2

H. pylori Testing and Eradication

Testing Strategy

• Test all patients with gastric ulcers for H. pylori infection using either urea breath test or stool antigen test 2, 5
• H. pylori infection increases the risk of NSAID-related complications by 2-4 fold 1, 3
• Testing during acute bleeding may yield false-negatives, so repeat testing if initially negative 2

Eradication Therapy (if H. pylori positive)

• Triple therapy regimen: PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 2, 6
• Alternative: Bismuth quadruple therapy or concomitant therapy (non-bismuth quadruple therapy) due to increasing clarithromycin resistance 5
• H. pylori eradication reduces the likelihood of peptic ulcers by one-half in NSAID users 5
• Eradication before starting NSAIDs reduces subsequent ulcer risk (from 26% to 7% over 8 weeks) 1

Risk Stratification and Long-Term Management

Patient Risk Assessment

• Very high risk category: History of ulcer complications—avoid all NSAIDs if possible 1
• High risk category: Multiple risk factors (age >60, cardiovascular disease, concomitant aspirin/anticoagulants/steroids) 1
• Older adults are at particularly high risk for NSAID-associated adverse events, which increase in frequency and severity with age 1

Long-Term Prevention Strategy

• If NSAIDs cannot be avoided: Use COX-2 selective inhibitor plus PPI for maximum gastroprotection 1, 4
• The combination of COX-2 inhibitor and PPI provides superior protection compared to either agent alone 4
• For patients on warfarin: COX-2 inhibitor plus misoprostol 1
• For patients on low-dose aspirin: COX-2 inhibitor plus PPI or misoprostol 1

Critical Warnings and Common Pitfalls

Medication Considerations

• H2-receptor antagonists are inadequate for NSAID-associated gastric ulcers—they only protect against duodenal ulcers, not gastric ulcers 2
• Standard-dose misoprostol (800 mg/day) is superior to PPIs for preventing gastric ulcers in H. pylori-negative NSAID users, but has significant side effects limiting tolerability 7, 8
• Poor compliance with gastroprotective agents increases the risk of NSAID-induced adverse events 4-6 fold 1, 3

H. pylori Eradication Nuances

• Among patients already on long-term NSAIDs, H. pylori eradication is less effective for preventing NSAID ulcers compared to NSAID-naïve patients 1, 9
• H. pylori eradication is most beneficial for primary prophylaxis (before starting NSAIDs) rather than secondary prevention (after ulcer has occurred) 7
• Despite reduced effectiveness in chronic NSAID users, all H. pylori-infected patients with peptic ulcers should receive eradication therapy regardless of NSAID use 7

Cardiovascular Considerations

• COX-2 inhibitors carry increased cardiovascular risk—avoid in patients where CV risk exceeds GI bleeding risk 1
• Some traditional NSAIDs (particularly ibuprofen) may interfere with the antiplatelet effect of aspirin 1
• Diclofenac has been identified as having potentially higher risk for adverse cardiovascular events 1

Alarm Symptoms Requiring Urgent Evaluation

• Seek immediate medical attention for: hematemesis (vomiting blood), melena (black tarry stools), significant weight loss, dysphagia (difficulty swallowing), or recurrent vomiting 2, 3
• These symptoms may indicate complications requiring urgent endoscopy or surgery 3