For a young patient with pleuritic chest pain who improves with naproxen but develops gastritis, what analgesic alternatives are appropriate and is a short course of oral methylprednisolone (Medrol‑dose pack) suitable?

Alternative Analgesics for Pleuritic Chest Pain with NSAID-Induced Gastritis

Switch to acetaminophen (up to 1000 mg every 6 hours) as the primary analgesic, and a methylprednisolone dose pack is reasonable for short-term use if pain remains inadequately controlled. 1, 2

Primary Analgesic Strategy

• Acetaminophen should be the first-line alternative when NSAIDs cause gastritis, as it provides effective analgesia for pleuritic pain without gastrointestinal toxicity 3, 1
• Dosing of 650-1000 mg every 6 hours (maximum 4000 mg/day) is appropriate for moderate pleuritic pain 3
• Unlike NSAIDs, acetaminophen has no antiplatelet activity or direct gastric mucosal effects 3

Role of Short-Course Corticosteroids

A methylprednisolone dose pack (Medrol Dosepak) is acceptable for short-term management of pleuritic pain, particularly when inflammation is prominent 3

• The typical dose pack provides 21 mg on day 1, tapering over 6 days, which falls within safe parameters for acute inflammatory conditions 3
• This short duration minimizes risks of hyperglycemia, immunosuppression, and other steroid-related adverse effects 3
• Corticosteroids directly reduce pleural inflammation, addressing the underlying pathophysiology rather than just masking pain 3

Important Caveats About Corticosteroid Use

• Screen for contraindications before prescribing: active infection (particularly tuberculosis or fungal), uncontrolled diabetes, peptic ulcer disease, or recent live vaccination 3
• Monitor blood glucose if the patient has diabetes or prediabetes, as even short courses can cause hyperglycemia 3
• Do not use corticosteroids as monotherapy if infection has not been excluded—pleuritic pain from pneumonia or empyema requires antibiotics as primary treatment 4, 5

Alternative Approaches if Steroids Are Contraindicated

• Opioid analgesics (such as tramadol 50 mg every 6 hours or low-dose oxycodone 5 mg every 6 hours) can be used for severe pleuritic pain when NSAIDs and steroids are inappropriate 3
• Titrate opioids carefully to avoid respiratory depression, particularly if pain limits deep breathing 3
• Consider topical or local anesthetic approaches if pain is highly localized 3

Addressing the Underlying Gastritis

• Proton pump inhibitors (PPIs) should be prescribed if the patient needs to resume NSAIDs in the future, as they significantly reduce gastric and duodenal ulcer risk 3
• Omeprazole 20-40 mg daily or equivalent PPI provides effective gastroprotection 3
• Test and treat for H. pylori if gastritis is recurrent or severe, as eradication reduces NSAID-associated complications 3
• Avoid combining NSAIDs with aspirin, other antiplatelet agents, anticoagulants, or corticosteroids, as this dramatically increases gastrointestinal bleeding risk 3

Clinical Decision Algorithm

1. Confirm the diagnosis: Ensure life-threatening causes (pulmonary embolism, pneumonia, myocardial infarction, pneumothorax, pericarditis) have been excluded through appropriate workup 1, 2
2. Switch to acetaminophen as first-line analgesic for mild-to-moderate pain 3, 1
3. Add methylprednisolone dose pack if pain is severe or inadequately controlled with acetaminophen alone 3
4. Reserve opioids for breakthrough pain or when both acetaminophen and steroids are contraindicated 3
5. Initiate PPI therapy to heal gastritis and enable future NSAID use if needed 3