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

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, such as omeprazole 20 mg once daily, while simultaneously discontinuing NSAIDs if possible. 1

Rationale for PPI as First-Line Therapy

• PPIs are superior to all other agents for healing NSAID-associated duodenal ulcers, with standard dosing of omeprazole 20 mg once daily providing rapid symptom relief and ulcer healing 1, 2
• The FDA label data demonstrates that omeprazole 20 mg heals 75% of duodenal ulcers by 4 weeks, significantly superior to placebo (27%) and comparable to H2-antagonists 2
• Over-the-counter antacids are insufficient for healing established duodenal ulcers and do not address the underlying pathophysiology 1
• Dietary modifications alone have no proven efficacy for ulcer healing 1

Why Not H. pylori Treatment First?

While H. pylori testing and eradication is critically important, PPI therapy should be initiated immediately for symptom control and ulcer healing before H. pylori results are available 1. Here's the algorithmic approach:

1. Start PPI immediately (omeprazole 20 mg once daily) 1, 2
2. Test for H. pylori infection in all patients with duodenal ulcer 1
3. Add H. pylori eradication therapy if positive: triple therapy with PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 1, 2

• Testing during acute symptoms may yield false-negatives, so repeat testing if initially negative 1
• H. pylori eradication prevents recurrent bleeding and ulcer recurrence, but this is added to PPI therapy, not instead of it 1

Critical NSAID Management

Discontinue NSAIDs immediately if possible 1, 3. This patient has chronic NSAID use for arthritis, which creates a management dilemma:

• If NSAIDs must be continued, maintain PPI co-therapy indefinitely for gastroprotection 1
• Patients with a history of NSAID-induced ulcers are at very high risk (approximately 10% annualized incidence of recurrent bleeding even with protective strategies) 4, 3
• Alternative analgesics should be strongly considered: acetaminophen 650 mg every 4-6 hours (maximum 4 grams daily) as first-line, or opioid analgesics if acetaminophen provides inadequate pain control 5
• For short-term anti-inflammatory therapy for acute, self-limiting arthritis (e.g., gout), steroids are recommended since steroids alone do not increase ulcer risk 4

Why Surgery is Not the Initial Step

Surgery is indicated only for complications such as:

• Bleeding refractory to endoscopic treatment 1
• Perforation 1
• Gastric outlet obstruction 1

This patient has no mention of these complications, making surgery inappropriate as an initial step.

Common Pitfalls to Avoid

• Do not use H2-receptor antagonists (ranitidine, cimetidine) as first-line therapy—they are significantly less effective than PPIs for duodenal ulcer healing 1
• Do not delay PPI therapy while waiting for H. pylori results—immediate acid suppression is essential for symptom relief and healing 1
• Do not allow the patient to continue NSAIDs without gastroprotection—this dramatically increases the risk of recurrent ulceration and complications 4, 3
• Poor compliance with gastroprotective therapy increases the risk of GI adverse events 4-6 fold 3

Summary Algorithm

1. Start omeprazole 20 mg once daily immediately (Answer C) 1, 2
2. Discontinue NSAIDs or switch to acetaminophen/opioids 1, 5
3. Test for H. pylori and add eradication therapy if positive 1
4. If NSAIDs cannot be discontinued, continue PPI indefinitely 1