Gastric Ulcers from Corticosteroids: What You Really Need to Know About Prevention and Monitoring

For years, doctors have been told to give proton pump inhibitors (PPIs) to anyone on corticosteroids-just to be safe. But what if that’s not helping at all? What if it’s doing more harm than good? The truth is, corticosteroids alone don’t cause gastric ulcers the way we thought. And giving PPIs to every patient on steroids might be one of the most common medical practices that’s not backed by evidence.

Why We Thought Corticosteroids Cause Ulcers

Corticosteroids like prednisone, dexamethasone, and methylprednisolone are powerful anti-inflammatory drugs. They’ve been used since the 1940s to treat everything from asthma to rheumatoid arthritis. For decades, doctors assumed they damaged the stomach lining the same way NSAIDs do-by reducing protective mucus and increasing acid. That logic made sense. So the standard became: high-dose steroid? Give a PPI.

But here’s the problem: the science never supported it.

A major 2013 review in Allergy, Asthma & Clinical Immunology looked at dozens of studies and found no increased risk of peptic ulcers in people taking corticosteroids alone. Even at high doses-like 60mg of prednisone daily-ulcer rates stayed around 0.4% to 1.8%. That’s lower than the rate of ulcers in people taking no medication at all in some populations.

So why did we keep doing it? Because symptoms are misleading. Steroids can cause stomach discomfort, bloating, or nausea. Patients feel it. Doctors see it. They assume it’s an ulcer forming. But those symptoms often don’t mean tissue damage is happening.

The Real Danger: When Steroids Meet NSAIDs

The real risk doesn’t come from steroids alone. It comes from stacking them with other drugs.

A study of Medicaid patients showed that when corticosteroids are taken with NSAIDs like ibuprofen or naproxen, the risk of a gastric ulcer jumps by 4.4 times. That’s not a small increase. That’s dangerous. And it’s the only scenario where the evidence clearly supports protective treatment.

Why? NSAIDs directly attack the stomach’s protective lining. Corticosteroids don’t do that. But they do slow down healing. So if an NSAID creates a tiny tear in the stomach wall, steroids make it harder for the body to fix it. The result? A bigger ulcer. A bleed. Maybe even a perforation.

This is why guidelines from the American College of Gastroenterology don’t recommend PPIs for steroid users unless they’re also on NSAIDs. Or unless they have a history of ulcers. Or if they’re on blood thinners like warfarin or apixaban. Those are the real red flags.

What About Hospitalized Patients?

Here’s where things get complicated. A 2014 review in BMJ Open found that hospitalized patients on corticosteroids had a 43% higher risk of GI bleeding. But outside the hospital? No increase at all.

Why the difference? Hospitalized patients are often sicker. They might be on multiple drugs. They might be NPO (nothing by mouth). They might have sepsis, trauma, or organ failure-all of which independently raise bleeding risk. In that setting, steroids might be just one factor in a storm of other dangers.

So if you’re admitted to the hospital and put on high-dose steroids? Yes, your doctor might still give you a PPI. But it’s not because of the steroid alone. It’s because you’re in a high-risk environment.

In outpatient settings-where most people take steroids for arthritis, lupus, or COPD-the risk is so low that the benefits of a PPI don’t outweigh the downsides.

Why PPIs Aren’t Harmless

PPIs like omeprazole, pantoprazole, and esomeprazole are widely used. But they’re not harmless. Long-term use is linked to:

• Increased risk of C. difficile infection
• Lower absorption of magnesium, vitamin B12, and calcium
• Higher chance of bone fractures in older adults
• Rebound acid hypersecretion when you stop them

Giving a PPI to someone who doesn’t need it isn’t just unnecessary-it’s exposing them to real, documented risks. And for what? To prevent something that rarely happens.

A 2021 quality improvement project at Johns Hopkins stopped routine PPIs for steroid-only patients. Over 12 months, PPI use dropped by 42.7%. No increase in ulcers. No bleeding. No emergency visits.

At the University of Wisconsin, they cut inappropriate PPI prescriptions by 35% after launching a simple rule: Only give PPIs if the patient is on NSAIDs, has a prior ulcer, or is in the hospital.

What Should You Actually Do?

If you’re prescribed corticosteroids, here’s what matters:

1. Ask if you’re also taking an NSAID. If yes, you likely need a PPI. If no, you probably don’t.
2. Check your history. Have you had a gastric ulcer before? Are you on blood thinners? If yes, talk to your doctor about protection.
3. Don’t assume stomach pain means an ulcer. Steroids can cause bloating, gas, or nausea without damaging your stomach. Don’t rush to ask for a PPI unless symptoms are severe or bloody.
4. Watch for alarm symptoms. If you vomit blood, pass black tarry stools, feel dizzy, or become pale and weak-get help immediately. These are signs of bleeding, not just irritation.
5. Ask about H. pylori. This bacteria causes most ulcers. If you’ve never been tested, ask your doctor. Treating it is more effective than any PPI.

Monitoring: What to Track and When

There’s no official checklist for monitoring steroid-induced ulcers because the risk is so low. But smart monitoring is still important:

• At start: Review all medications. Flag NSAIDs, anticoagulants, SSRIs. Test for H. pylori if you have a history of GI issues.
• At 1-2 weeks: Note any new stomach pain, nausea, or appetite loss. Don’t panic-but don’t ignore it either.
• At 1 month: Check for signs of anemia (fatigue, pale skin, shortness of breath). A simple blood test can catch slow bleeding before it becomes serious.
• Every 3-6 months: If you’re on long-term steroids, get your blood sugar checked. Steroids raise glucose levels, especially after meals. This is far more common than ulcers.

Endoscopy? Only if you have alarm symptoms. Routine scopes for steroid users? Not recommended. Too invasive. Too expensive. And unnecessary.

The Bigger Picture: Why This Matters

This isn’t just about one drug. It’s about how medicine works-and sometimes doesn’t work.

We’ve been giving PPIs to steroid patients for decades because it felt right. Because we saw symptoms. Because we feared complications. But medicine isn’t about feeling right. It’s about what the data shows.

The Things We Do for No Reason™ movement-started by hospitalists tired of doing things without evidence-is gaining ground. More hospitals are auditing their PPI use. More doctors are asking: Do I really need to prescribe this?

And the answer, for most steroid users, is no.

The American Gastroenterological Association is now reviewing its guidelines on this exact issue. A clinical trial (NCT05214345) is underway to compare ulcer rates in steroid users with and without PPIs. Results are expected in late 2024.

Until then, the safest approach is the simplest: don’t treat a risk that doesn’t exist. Treat the real ones.

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