From the Guidelines
The best next step in care for this patient is to stop ibuprofen and naproxen, start esomeprazole, and refer for outpatient evaluation. This 47-year-old man is presenting with classic symptoms of peptic ulcer disease, likely caused by his chronic use of NSAIDs (ibuprofen and naproxen) for back pain. NSAIDs inhibit prostaglandin synthesis, which reduces the protective mucus layer in the stomach and duodenum, making them vulnerable to acid damage. The patient's epigastric burning pain, bloating, and nausea for 3 weeks are typical manifestations of this condition. Esomeprazole, a proton pump inhibitor, will reduce gastric acid production, allowing the gastric mucosa to heal. The standard dosage is 40mg once daily for 4-8 weeks 1. Discontinuing the offending NSAIDs is crucial to prevent further damage. Outpatient follow-up is appropriate since the patient is hemodynamically stable without signs of complications like bleeding or perforation. Alternative pain management strategies for his chronic back pain should also be discussed during follow-up. If symptoms persist despite these interventions, endoscopy may be indicated to evaluate for H. pylori infection or other pathologies, as suggested by the guidelines for non-variceal upper gastrointestinal haemorrhage 1. Additionally, the British Society of Gastroenterology guidelines on the management of functional dyspepsia support the use of proton pump inhibitors and the consideration of H. pylori eradication therapy in patients with peptic ulcer disease 1. The ACR Appropriateness Criteria for epigastric pain also recommend the use of proton pump inhibitors and the consideration of endoscopy in patients with suspected peptic ulcer disease 1. Overall, the patient's symptoms and presentation suggest peptic ulcer disease, and the recommended treatment with esomeprazole and discontinuation of NSAIDs is supported by the available evidence.
From the FDA Drug Label
Naproxen, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis
The patient is experiencing epigastric pain, which is a sign of potential GI side effects from naproxen.
- Stop ibuprofen and naproxen to prevent further GI irritation.
- Start esomeprazole to reduce stomach acid and help heal any potential ulcers.
- Refer for outpatient evaluation to monitor the patient's condition and adjust treatment as needed. 2
From the Research
Patient Presentation and History
The patient is a 47-year-old man with chronic lower back pain, presenting with epigastric pain, bloating, and nausea for 3 weeks. He is currently taking ibuprofen and naproxen for his back pain.
Current Symptoms and Vital Signs
- Epigastric pain described as burning without radiation
- Associated symptoms: bloating and nausea
- Vital signs: BP 122/82 mm Hg, HR 88 bpm, RR 17/minute, SpO2 99% on room air, T 98.6°F
Best Next Step in Care
Given the patient's symptoms and history of NSAID use, the best next step involves addressing the potential cause of his epigastric pain, which could be related to NSAID-induced gastric ulcers or gastroesophageal reflux disease (GORD). The evidence suggests that stopping NSAIDs and starting a proton pump inhibitor (PPI) like esomeprazole can be effective in healing NSAID-associated gastric ulcers and preventing further gastrointestinal complications 3, 4, 5, 6, 7.
Recommended Action
- Stop ibuprofen and naproxen to prevent further gastric irritation.
- Start esomeprazole to reduce gastric acid secretion and promote healing of any potential ulcers.
- Refer for outpatient evaluation to monitor the patient's condition and adjust the treatment plan as necessary.
Rationale
Esomeprazole has been shown to be effective in healing NSAID-associated gastric ulcers and in preventing ulcers in patients at risk, including those taking NSAIDs for chronic conditions 4, 7. Its efficacy in promoting ulcer healing and preventing recurrence, along with its tolerability, makes it a suitable choice for this patient 3, 5, 6.