What is the appropriate treatment for chronic gastritis in a 72‑year‑old woman taking cilostazol who has not responded to omeprazole?

Treatment Approach for PPI-Refractory Chronic Gastritis in a 72-Year-Old on Cilostazol

Escalate omeprazole to 20 mg twice daily (before breakfast and dinner) for 4-8 weeks, as this is the evidence-based next step when standard-dose PPI therapy fails in elderly patients with dyspepsia. 1

Immediate Management Strategy

Optimize Current PPI Therapy

• Increase omeprazole to twice-daily dosing (20 mg before breakfast and 20 mg before dinner) for at least 4-8 weeks, as the American College of Gastroenterology specifically recommends dose escalation when symptoms persist after initial therapy 1
• Ensure the patient takes omeprazole 30-60 minutes before meals, as improper timing significantly reduces efficacy 2
• Continue cilostazol without interruption, as there are no significant interactions requiring discontinuation 2

Rule Out H. pylori Infection

• Test for H. pylori immediately if not already done, as 70% of chronic gastritis cases in this age group are H. pylori-positive 3
• If H. pylori is present, eradicate with omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily for 7-14 days 4
• H. pylori eradication is critical because omeprazole alone does not eliminate the infection and may worsen atrophic gastritis in infected patients 5, 6

Critical Medication Review

Assess for Occult NSAID/Aspirin Use

• Document complete medication history including over-the-counter medications, as hidden NSAID use is a common cause of PPI failure and requires different management 7
• At age 72 with cilostazol use (indicating peripheral arterial disease), she may be on aspirin or other antiplatelet agents that significantly impair gastric healing 2
• If NSAIDs cannot be discontinued, add PPI gastroprotection at twice-daily dosing, as H2-receptor antagonists provide inadequate protection 2, 7

When to Pursue Endoscopy

Perform upper endoscopy if symptoms persist after 8 weeks of optimized PPI therapy, as this is indicated in elderly patients (>60 years) and those with treatment failure 2

Endoscopic Evaluation Should Include:

• Assessment for erosive gastritis, peptic ulcer disease, and gastric malignancy (higher risk in this age group) 2
• Multiple biopsies from antrum and corpus for H. pylori testing and histological grading of gastritis 3
• Evaluation for atrophic gastritis and intestinal metaplasia, particularly if long-term PPI use is documented 6

Alternative PPI Options

If omeprazole twice daily fails after 8 weeks:

• Switch to a more potent PPI such as esomeprazole or rabeprazole (less CYP2C19 metabolism) or dexlansoprazole (extended-release formulation) 2
• Pantoprazole 40 mg twice daily is an acceptable alternative, though it has less robust dyspepsia-specific evidence 1

Adjunctive Lifestyle Modifications

• Elevate head of bed and avoid meals within 3 hours of bedtime to reduce nocturnal acid exposure 2
• Weight management if applicable, as increased intra-abdominal pressure worsens gastritis symptoms 2
• Stress reduction strategies and discussion of brain-gut axis, as psychological factors influence symptom severity 2

Common Pitfalls to Avoid

• Do not continue standard-dose omeprazole indefinitely without dose escalation – this delays appropriate treatment 1
• Do not assume H. pylori-negative status without testing – 70% of chronic gastritis in elderly patients is H. pylori-associated 3
• Do not switch to H2-receptor antagonists – they provide inadequate gastroprotection compared to PPIs 2, 7
• Do not delay endoscopy beyond 8 weeks of optimized therapy in a 72-year-old, as age is an independent risk factor for gastric malignancy 2

Long-Term Management

• After achieving symptom control, taper to the lowest effective PPI dose rather than continuing full-dose therapy indefinitely 1
• Consider on-demand therapy (taking PPI only when symptoms occur) after initial treatment success to minimize long-term exposure 1
• If H. pylori was eradicated, confirm eradication with breath test 4-8 weeks after completing antibiotics 4