A 48-year-old woman with chronic NSAID use (ibuprofen 400 mg TDS for arthralgia) develops a duodenal ulcer confirmed on endoscopy. H. pylori serology is negative. What is the drug of choice for ulcer healing and prevention of recurrence?

Explanation

## NSAID-Induced Peptic Ulcer Management **Key Point:** Proton pump inhibitors (PPIs) are the drug of choice for both healing and prevention of NSAID-induced peptic ulcers. They are superior to H2-receptor antagonists and other agents in this setting. ### Why PPI for NSAID Ulcers? | Feature | PPI (Omeprazole) | H2-RA (Ranitidine) | Sucralfate | Antacids | |---------|------------------|-------------------|-----------|----------| | **Healing rate** | >95% at 4 weeks | ~80% at 4 weeks | ~85% | ~70% | | **Prevention of recurrence** | Excellent (>90%) | Moderate (~70%) | Moderate | Poor | | **Mechanism** | ↓ Acid secretion by 90%+ | ↓ Acid secretion by 60–70% | Mucosal protection | Neutralization only | | **Guideline recommendation** | **First-line** | Alternative | Alternative | Not recommended | **High-Yield:** PPIs achieve intragastric pH >4 for >18 hours/day, which is necessary for NSAID ulcer healing. H2-RAs maintain pH >4 for only 8–10 hours, making them inadequate monotherapy. ### Management Algorithm for NSAID Ulcers ```mermaid flowchart TD A[NSAID-induced ulcer diagnosed]:::outcome --> B{Continue NSAID?}:::decision B -->|No| C[Stop NSAID + PPI for 4-8 weeks]:::action B -->|Yes| D[Switch to COX-2 inhibitor or add gastroprotection]:::action C --> E[Omeprazole 20 mg OD]:::action D --> F[Omeprazole 20 mg OD + continue NSAID]:::action E --> G[Ulcer healed at 4-8 weeks]:::outcome F --> H[Ulcer healed + recurrence prevented]:::outcome ``` **Clinical Pearl:** If the NSAID must be continued (e.g., for severe arthritis), PPI prophylaxis at standard dose (omeprazole 20 mg OD) reduces ulcer recurrence from ~25% to <5%. **Mnemonic:** **PPI-NSAID** = Proton Pump Inhibitor is the gold standard for NSAID-induced ulcer disease. ### Dosing for NSAID Ulcer Healing - **Omeprazole:** 20 mg once daily for 4–8 weeks (healing) - **Omeprazole:** 20 mg once daily indefinitely (if NSAID must continue) - **Lansoprazole:** 30 mg once daily (alternative PPI) - **Pantoprazole:** 40 mg once daily (alternative PPI) **Warning:** Do NOT use H2-RAs as monotherapy for NSAID ulcers — they have insufficient acid suppression and higher recurrence rates. Sucralfate requires QID dosing and is less convenient. [cite:Harrison 21e Ch 297]