Pharmacotherapy Case Study 3: NSAID-Induced Ulcer Disease By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 3: NSAID-Induced Ulcer Disease By: Dr. Nehad Ahmed

 

Chief Complaint:

A 55-year-old male presents with complaints of burning epigastric pain, nausea, and indigestion for the past 3 weeks. The pain is described as dull and aching, occurring about 1-2 hours after meals and frequently exacerbated by taking ibuprofen.

Subjective Data:

History of Present Illness (HPI):

·        The patient reports a constant burning pain in the upper abdomen for the past 3 weeks. The pain is worst after meals and typically resolves somewhat with antacids but returns after a few hours.

·        The patient also describes bloating and occasional nausea, particularly after eating.

·        The pain seems to worsen when he takes ibuprofen for his chronic joint pain (knee osteoarthritis). The patient admits to taking 400 mg of ibuprofen 2-3 times per day for several months for pain relief.

·        The patient denies any history of heartburn or gastroesophageal reflux disease (GERD) prior to this.

·        No vomiting, melena, or hematemesis, but the patient notes occasional dark stools (not confirmed as melena).

·        Denies weight loss, fever, or chills.

Past Medical History (PMH):

·        Chronic osteoarthritis of the knees, diagnosed 5 years ago.

·        Hypertension, well-controlled with an ACE inhibitor.

·        No history of gastrointestinal diseases or ulcers.

Medications:

·        Ibuprofen 400 mg orally 2-3 times daily for knee pain.

·        Lisinopril 10 mg orally once daily for hypertension.

·        Occasionally uses antacids (calcium carbonate) for symptom relief.

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Works as an accountant, mostly sedentary.

·        Smokes half a pack of cigarettes daily for 30 years.

·        Consumes alcohol socially (2-3 drinks per week).

·        Denies illicit drug use.

·        High stress at work, reports little exercise or physical activity.

Family History:

·        Father with a history of myocardial infarction and hypertension.

·        Mother with a history of peptic ulcers.

Review of Systems (ROS):

·        Gastrointestinal: Positive for epigastric burning pain, bloating, and nausea. Occasional dark stools but denies vomiting, hematemesis, or diarrhea.

·        Cardiovascular: Denies chest pain, palpitations, or shortness of breath.

·        Respiratory: No cough, shortness of breath, or wheezing.

·        Neurological: No headaches, dizziness, or syncope.

·        Musculoskeletal: Chronic knee pain with decreased mobility.

Objective Data:

Vital Signs:

·        Blood Pressure: 128/80 mmHg

·        Heart Rate: 78 bpm

·        Respiratory Rate: 16 breaths/min

·        Temperature: 98.7°F (37.1°C)

·        Weight: 210 lbs (95 kg)

·        Height: 5'9" (175 cm)

Physical Exam:

·        General: Alert, oriented, and in no acute distress.

·        Abdomen: Mild epigastric tenderness on deep palpation, no rebound tenderness or guarding. No palpable masses. Bowel sounds are normal.

·        Cardiovascular: Regular rate and rhythm, no murmurs.

·        Respiratory: Clear to auscultation bilaterally.

·        Musculoskeletal: Decreased range of motion in both knees, with mild swelling and tenderness.

Labs and Imaging:

·        Complete Blood Count (CBC): Normal WBC, hemoglobin, and platelet count.

·        Basic Metabolic Panel (BMP): Normal electrolytes and renal function.

·        Liver Function Tests (LFTs): Normal.

·        Helicobacter pylori testing: Negative (urea breath test).

·        Endoscopy: Findings consistent with a gastric ulcer (shallow ulcer with a clean base, no signs of bleeding or perforation).

·        Stool Occult Blood Test: Negative for occult blood.

Assessment:

The patient is diagnosed with NSAID-induced Peptic Ulcer Disease, likely caused by prolonged use of ibuprofen for chronic osteoarthritis. The patient’s gastric ulcer was confirmed on endoscopy, and the negative H. pylori test suggests that the ulcer is most likely secondary to NSAID use rather than an infectious cause.

 

Plan:

Pharmacologic Treatment:

1.     Proton Pump Inhibitor (PPI):

o   Omeprazole 20 mg orally once daily for 4-6 weeks to reduce gastric acid secretion and promote ulcer healing.

2.     Antacids (as needed for symptom relief):

o   Calcium carbonate 500 mg after meals and at bedtime for occasional heartburn.

3.     H2 Receptor Antagonist (if needed for additional symptom control):

o   Ranitidine 150 mg orally twice daily for additional acid suppression.

4.     Alternative analgesics:

o   Recommend transitioning from NSAIDs to acetaminophen 500 mg orally every 4-6 hours as needed for pain relief, with a maximum of 3000 mg per day to minimize gastrointestinal irritation.

o   Discuss with the patient about the possibility of using other joint pain management strategies, such as physical therapy or topical analgesics.

Non-pharmacologic Treatment:

·        Dietary modifications: Encourage avoiding spicy foods, caffeine, and alcohol, which may exacerbate ulcer symptoms.

·        Lifestyle modifications: Recommend cessation of smoking to improve ulcer healing and reduce overall gastrointestinal risk.

·        Stress management: Suggest relaxation techniques such as yoga or deep breathing exercises.

·        Follow-up: In 4-6 weeks to reassess symptoms and confirm healing. If symptoms persist, consider repeating endoscopy.

Patient Education:

·        Emphasize the importance of avoiding NSAIDs and recommend safer pain management strategies.

·        Instruct the patient to complete the full course of PPI therapy.

·        Discuss the risks of continued smoking and alcohol consumption on gastrointestinal health.

·        Advise the patient to monitor for signs of gastrointestinal bleeding (e.g., dark stools or vomiting blood) and seek immediate medical attention if these occur.

Follow-Up:

·        Schedule a follow-up appointment in 4-6 weeks to assess symptom resolution and to discuss further management of joint pain without NSAIDs. Repeat endoscopy if needed to assess ulcer healing and ensure the absence of complications.