A 60-year-old man on aspirin 75 mg daily and naproxen for osteoarthritis develops an upper GI bleed. EGD shows a 1.2 cm gastric ulcer. H. pylori testing is negative. He cannot stop aspirin (post-MI secondary prevention). What is the most appropriate long-term management to prevent recurrent peptic ulcer bleeding?

• A Stop naproxen; continue aspirin; add a full-dose PPI indefinitely ✓
• B Switch naproxen to a COX-2 selective inhibitor; no PPI needed if H. pylori negative
• C Continue both NSAIDs; add misoprostol for gastro-protection
• D Stop aspirin to allow ulcer healing; restart after 8 weeks

Explanation

In a patient who cannot stop aspirin (established cardiovascular indication), the non-aspirin NSAID (naproxen) should be discontinued as it confers the primary ulcer risk. Concurrent PPI (full dose, indefinitely) is required when aspirin must continue after GI bleeding. Misoprostol is poorly tolerated. Stopping aspirin post-MI carries significant thrombotic risk and should be avoided unless haemostasis cannot be achieved.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.