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After completing this case study, the reader should be able to:

  • Determine whether patients with diabetes who have risk factors for NSAID-induced ulcer disease should remain on aspirin and at what dose.

  • Identify the hallmark signs and symptoms of NSAID-induced PUD.

  • Recommend appropriate therapy for the treatment of NSAID-induced PUD while taking into account Helicobacter pylori infection and its appropriate diagnosis and follow-up.

  • Recommend alternative therapies besides traditional NSAIDs for treatment of pain and inflammation in patients with PUD.

  • Educate patients effectively on treatment options for NSAID-induced PUD.


Chief Complaint

“I have had constant stomach pain, nausea, and bloating in the last 2 weeks.”


Shirley Jackson is a 72-year-old woman who presents to the emergency department for epigastric pain, early satiety, and nausea for 2 weeks. She normally takes OTC Zantac for her symptoms, which she states is usually sufficient; however, this time the symptoms persisted. When asked about any recent medication changes, she admits to frequent naproxen use the past 2 weeks for increased osteoarthritis pain.



OA primarily in right wrist/hand and knees


Type 2 DM

S/P appendectomy after appendicitis in the 1980s


Father died of MI at age 65; mother died of cervical CA in her eighties.


Retired school teacher; smoked one pack per day for 15 years, quit 6 years ago; drinks one alcoholic drink per day but admits to occasionally having more


ASA 325 mg PO once daily

Lisinopril 20 mg PO once daily

Amlodipine 10 mg PO once daily

Metformin 1000 mg PO twice daily

Atorvastatin 40 mg PO nightly

OTC naproxen 200 mg, two tablets PO one to four times daily for OA pain

OTC ranitidine 75 mg, one tablet two to three times daily for heartburn


Codeine (rash); penicillin (rash/hives)


Denies headache or chest pain. Occasional SOB. Positive heartburn. No weakness, polyphagia, polydipsia, or polyuria. Gait slow but steady. Complains of some chronic pain in left knee, which she has been told is from OA.

Physical Examination


The patient is a pleasant woman in mild distress.



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