What is the treatment for a patient with duodenal or GI ulcers, possibly related to NSAID use or H. pylori infection?

Treatment of Duodenal and Gastrointestinal Ulcers

Immediately discontinue all NSAIDs, initiate a proton pump inhibitor (PPI) at standard dosing (omeprazole 20-40 mg daily or lansoprazole 30 mg daily), and test for H. pylori with eradication therapy if positive. 1, 2, 3

Immediate Management Steps

• Discontinue all NSAIDs immediately if possible, as they are a primary cause of gastroduodenal ulcers and significantly increase recurrence risk even with PPI therapy 2, 3
• Initiate PPI therapy immediately: Start omeprazole 20 mg once daily or lansoprazole 15-30 mg once daily for duodenal ulcers, or omeprazole 40 mg once daily for gastric ulcers 4, 5, 6
• Take PPIs 30 minutes before meals for optimal acid suppression 7, 2
• Counsel complete smoking cessation, as smoking impairs ulcer healing and increases complication rates 2, 3
• Avoid combining NSAIDs with antiplatelet drugs, anticoagulants, or corticosteroids, as these combinations dramatically increase ulcer risk 7, 2

H. pylori Testing and Eradication

• Test all patients with peptic ulcers for H. pylori infection using urea breath test or stool antigen test (preferred over serology) 1, 3
• Be aware that testing during acute bleeding may yield false-negative results; perform confirmatory testing after the acute phase if initial test is negative 1, 3
• Eradicate H. pylori before starting chronic NSAID therapy in patients with a history of ulcer disease, as this is a critical preventive measure 7

Triple Therapy (First-Line)

• Standard triple therapy for 14 days: PPI (omeprazole 20 mg or lansoprazole 30 mg) + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily 1, 4, 5, 8
• 10-day triple therapy is equivalent to 14-day therapy for H. pylori eradication 5

Dual Therapy (Alternative)

• For patients allergic or intolerant to clarithromycin: Lansoprazole 30 mg three times daily + amoxicillin 1 g three times daily for 14 days 5
• Dual therapy is less effective than triple therapy and should only be used when clarithromycin cannot be given 5

Treatment Duration and Healing

• Duodenal ulcers: Most heal within 4 weeks; some require an additional 4 weeks of PPI therapy 4, 5
• Gastric ulcers: Treat for 4-8 weeks with PPI therapy 4, 5
• Confirm H. pylori eradication 4-6 weeks after completing therapy using non-serological testing 2, 3

NSAID-Associated Ulcer Management

If NSAIDs Cannot Be Discontinued

• Continue omeprazole 40 mg once daily indefinitely for gastroprotection while on NSAIDs 2, 3
• Consider switching to a COX-2 selective inhibitor (celecoxib) plus PPI in high-risk patients 7, 2, 3
• Use the lowest effective NSAID dose for the shortest duration possible 2, 3
• H. pylori eradication alone is insufficient to prevent NSAID-induced damage in patients with previous ulcer history; additional PPI therapy is mandatory 7, 2

High-Risk Patients

High-risk patients (those with previous ulcer bleeding, elderly, or on anticoagulants) require:

• Intensive gastroprotection with PPI plus COX-2 inhibitor 7, 2
• PPI therapy is superior to H. pylori eradication alone for preventing recurrent bleeding in NSAID users 7

Management of Bleeding Ulcers

• Administer high-dose PPI therapy: 80 mg omeprazole bolus followed by 8 mg/hour continuous infusion for 72 hours after endoscopic hemostasis for high-risk stigmata 1, 3
• Transition to standard oral PPI therapy (omeprazole 20 mg once daily) following the 72-hour infusion 1
• Endoscopy is first-line for diagnosis and management of bleeding ulcers 3

Follow-Up and Maintenance Therapy

• After successful H. pylori eradication, maintenance PPI therapy is generally not necessary for uncomplicated ulcers 1, 2, 3
• Indefinite PPI therapy is required if NSAIDs must be continued after ulcer healing 2, 3
• For patients on aspirin for cardiovascular disease with previous ulcer bleeding, continue PPI therapy indefinitely 7, 3
• Endoscopic confirmation of healing is not routinely necessary unless the patient must continue NSAID therapy 1, 2
• For gastric ulcers, perform follow-up endoscopy approximately 6 weeks after hospital discharge to confirm healing and exclude malignancy 3

Critical Warnings and Common Pitfalls

• Do NOT use H2-receptor antagonists (ranitidine, cimetidine) as first-line therapy: They reduce duodenal ulcer risk but NOT gastric ulcer risk, making them inadequate for gastric ulcer treatment 7, 1, 2, 3
• Poor compliance with PPI therapy increases NSAID-induced adverse events 4-6 fold; emphasize adherence 2, 3
• Misoprostol (200 µg four times daily) is effective but causes abdominal cramps and diarrhea in ~20% of patients, limiting its use despite being the only agent proven to reduce ulcer complications by 40% 7
• Long-term PPI use may be associated with increased risks of pneumonia, hip fracture, Clostridium difficile infection, chronic kidney disease, and micronutrient deficiencies; use the lowest effective dose for maintenance therapy 7, 1, 2, 3
• Among NSAID users with bleeding ulcers, H. pylori is an independent risk factor (OR 4.7) along with previous ulcer history (OR 15.2) and alcohol use (OR 4.2) 7
• PPI plus H. pylori eradication is superior to H. pylori eradication alone for preventing recurrent ulcer complications in aspirin users 7