American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the recommended management for a patient with high gastrointestinal risk requiring oral NSAIDs?

1. Prescribe a higher dose of NSAIDs

2. Simultaneously switch to celecoxib and add a PPI

3. Limit the duration of NSAID usage

4. Only use topical NSAIDs

The correct answer is: Simultaneously switch to celecoxib and add a PPI

The recommended management for a patient with high gastrointestinal risk who requires oral NSAIDs is to switch to a selective COX-2 inhibitor, such as celecoxib, while also adding a proton pump inhibitor (PPI). This combination is effective in balancing the need for pain management with the mitigation of gastrointestinal risks associated with non-selective NSAIDs. Celecoxib, as a COX-2 selective inhibitor, tends to have a lower incidence of gastrointestinal complications compared to traditional NSAIDs because it spares the COX-1 pathway, which is responsible for maintaining the protective gastric mucosa. Therefore, using celecoxib can help reduce the risk of gastrointestinal irritation and ulceration. Adding a PPI further helps by decreasing gastric acidity, which not only protects the stomach lining but also decreases the risk of developing NSAID-induced gastric ulcers. This combined approach is particularly beneficial for patients at high risk of gastrointestinal problems, such as those with a history of ulcers or older patients. Other options mentioned, such as prescribing a higher dose of NSAIDs, limiting the duration of NSAID usage, or only using topical NSAIDs may not adequately address the gastrointestinal risks associated with systemic NSAID therapy for patients who require ongoing treatment for pain. High doses of NSAIDs can