What is the best approach for managing gastritis pain in a patient, considering factors such as NSAID (Non-Steroidal Anti-Inflammatory Drug) use and H. pylori infection?

Gastritis Pain Management

For gastritis pain, immediately start a high-potency proton pump inhibitor (PPI) such as esomeprazole 40mg once daily or rabeprazole 20mg twice daily, discontinue all NSAIDs if possible, and test for H. pylori with eradication therapy if positive. 1, 2

Immediate Pain Control and Acid Suppression

PPIs are the first-line treatment for gastritis pain relief and mucosal healing. 2 High-potency options provide superior symptom control:

• Esomeprazole 20-40mg twice daily (equivalent to 32mg omeprazole) 2
• Rabeprazole 20mg twice daily (equivalent to 36mg omeprazole) 2
• Lansoprazole 30mg twice daily (equivalent to 27mg omeprazole) 2
• Avoid pantoprazole when possible due to lower potency (40mg pantoprazole = only 9mg omeprazole) 2

Continue PPI therapy for a full 8 weeks to ensure complete healing, then attempt gradual dose reduction or on-demand therapy based on symptom response. 1, 2

Antacids can be used for rapid breakthrough symptom relief while awaiting PPI effect. 2

NSAID-Related Gastritis Management

If NSAIDs are the cause, discontinue them immediately as they significantly increase ulcer recurrence risk even with PPI therapy. 1

• Use acetaminophen as an alternative for pain relief, which does not cause gastric injury 1
• If NSAIDs are absolutely necessary, use the lowest effective dose for the shortest duration 2
• Combine a COX-2 selective inhibitor (celecoxib) with a PPI for high-risk patients requiring continued NSAID therapy 3, 1

Critical warning: Never use NSAIDs again without gastroprotection, as patients with NSAID-induced gastritis are at very high risk for recurrent complications. 1 Poor PPI compliance increases adverse event risk 4-6 fold. 1

Gastroprotective Strategies for Unavoidable NSAID Use

For patients who cannot discontinue NSAIDs:

• PPIs reduce endoscopic NSAID-related ulcers by 90% and are the preferred gastroprotective agent 3
• Misoprostol 600-800mg daily reduces NSAID-associated GI complications by 40% and gastric ulcers by 74%, but causes diarrhea and abdominal pain in ~20% of patients, limiting tolerability 3, 4
• H2-receptor antagonists are inadequate - they decrease duodenal ulcer risk but not gastric ulcer risk 3

H. pylori Testing and Eradication

Test all gastritis patients for H. pylori infection immediately, as it increases NSAID-related complications 2-4 fold. 1, 2

If H. pylori is positive, eradicate with bismuth quadruple therapy for 14 days (PPI + bismuth + metronidazole + tetracycline) due to increasing clarithromycin resistance. 2, 5

Alternative first-line option when bismuth unavailable:

• Triple therapy: PPI + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 1, 6

H. pylori eradication is particularly important before starting long-term NSAID therapy, as short-term studies show eradication decreases peptic ulcer incidence in NSAID-naive patients. 3 However, eradication alone is insufficient in high-risk patients - continue PPI co-therapy. 3

Confirm successful eradication with non-serological testing (urea breath test or stool antigen), as residual symptoms are common even after successful treatment. 2

Risk Stratification and Monitoring

High-risk patients requiring intensive gastroprotection include those with: 3

• History of previous ulcer or ulcer complication
• Age >65 years
• Concomitant corticosteroid use
• High-dose or multiple NSAID use
• Anticoagulant or antiplatelet therapy

For high-risk patients on NSAIDs: combine COX-2 inhibitor with PPI, though this does not eliminate risk entirely. 3

Common Pitfalls to Avoid

• Inadequate PPI dosing or timing - take 30 minutes before meals for optimal effect 2
• Premature discontinuation - complete the full 8-week course even if symptoms improve 1
• Failure to address H. pylori - testing and eradication are essential 2
• Using buffered or coated aspirin - these do not significantly decrease GI risk 3
• Combining NSAIDs - polypharmacy dramatically increases risk, especially with aspirin 3

Alarm Symptoms Requiring Urgent Evaluation

Seek immediate medical attention if any of these develop: 1

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Significant unintentional weight loss
• Dysphagia (difficulty swallowing)
• Recurrent vomiting

These may indicate complications requiring urgent endoscopy or surgery. 1