What is the recommended medication for a patient diagnosed with gastritis, considering potential underlying causes and contributing factors such as NSAID use?

Medication for Gastritis

Proton pump inhibitors (PPIs) are the first-line medication for gastritis, with high-potency options like esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily being most effective for symptom relief and mucosal healing. 1

First-Line Treatment Strategy

For uncomplicated gastritis without NSAID use:

• Start with high-potency PPIs: esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily 1, 2
• Lansoprazole 30 mg twice daily is an alternative option 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole) 1
• Take PPIs 30 minutes before meals for optimal effectiveness 1

Critical timing consideration: PPIs must be taken 30 minutes before eating to maximize acid suppression—inadequate timing is a common pitfall that reduces treatment effectiveness. 1

NSAID-Associated Gastritis Management

If gastritis is NSAID-related, immediately discontinue all NSAIDs if clinically feasible. 2, 3 This is the single most important intervention, as continued NSAID use dramatically increases risk of complications even with PPI therapy. 3

For patients who must continue NSAIDs:

• Add PPI therapy at full dose (esomeprazole 40 mg once daily) for gastroprotection 4, 3
• PPIs reduce NSAID-related ulcers by 90% 4
• Consider switching to a COX-2 selective inhibitor (like celecoxib) combined with a PPI for high-risk patients 4
• Use the lowest effective NSAID dose for the shortest duration 4

High-risk patients requiring intensive gastroprotection include: those with prior ulcer history, age >65 years, concurrent corticosteroid use, concurrent anticoagulation/antiplatelet therapy, or high-dose/multiple NSAID use. 4 These patients should receive a COX-2 inhibitor plus PPI for maximum protection. 4

Critical warning: H2-receptor antagonists (like ranitidine) are inadequate for gastroprotection—they decrease duodenal ulcer risk but NOT gastric ulcer risk. 4, 2 Do not substitute H2-blockers for PPIs in NSAID users. 2

H. pylori Testing and Treatment

Test every gastritis patient for H. pylori infection using urea breath test (sensitivity 88-95%) or monoclonal stool antigen test (sensitivity 94%). 1, 2

If H. pylori positive, treat with bismuth quadruple therapy for 14 days:

• High-potency PPI twice daily 1
• Bismuth 1
• Metronidazole 500 mg twice daily 1
• Tetracycline 1

This regimen is preferred over clarithromycin-based triple therapy due to increasing antibiotic resistance. 1, 5

H. pylori eradication is particularly critical before starting long-term NSAID therapy, especially in patients with previous ulcer history. 4, 1 However, eradication alone is insufficient in patients requiring continued NSAIDs—both PPI therapy AND H. pylori eradication are necessary. 4, 3

Confirm successful eradication after treatment using non-serological testing—relying solely on symptom resolution without confirmation can lead to persistent infection and complications. 1

Treatment Duration and Follow-Up

• Continue PPI therapy for a full 8 weeks to ensure complete healing 3
• After symptom resolution, attempt a trial withdrawal of PPI therapy 3
• If symptoms recur, resume PPI therapy on-demand or continuously 3

Warn patients about rebound acid hypersecretion (RAHS): When discontinuing long-term PPI therapy, patients may develop transient upper GI symptoms that typically resolve within 6 months. 4 H2-receptor antagonists or antacids can be used as-needed for these withdrawal symptoms. 4

Alternative and Adjunctive Therapies

Misoprostol (600-800 mg daily) reduces NSAID-associated gastric ulcers by 74%, but causes diarrhea and abdominal pain in ~20% of patients, limiting its tolerability. 4, 1 It is not a first-line option due to side effects. 4

Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms. 1

Acetaminophen should be used as an alternative for pain relief in patients with gastritis, as it does not cause gastric injury. 3

Critical Pitfalls to Avoid

• Never combine multiple NSAIDs—this dramatically increases GI risk 4
• Buffered or coated aspirin does NOT significantly decrease GI risk 4
• Poor compliance with PPI therapy increases risk of NSAID-induced adverse events 4-6 fold 3
• Never use NSAIDs again without gastroprotection in patients with previous NSAID-induced gastritis 3

Seek immediate medical attention for alarm symptoms: hematemesis, melena, significant weight loss, difficulty swallowing, or recurrent vomiting—these may indicate complications requiring urgent endoscopy. 3