Gastric Ulcers from Corticosteroids: Prevention and Monitoring

For years, doctors have assumed that taking corticosteroids like prednisone puts you at high risk for stomach ulcers. But the truth is more complicated than that. If you're on steroids alone - no NSAIDs, no history of ulcers, not in the hospital - your risk of developing a gastric ulcer is extremely low. In fact, studies show it’s around 0.4% to 1.8%. That’s less than 2 in 100 people. Yet, most patients on steroids are still handed a proton pump inhibitor (PPI) like omeprazole as a matter of routine. Why? Because old habits die hard.

What’s Really Going On With Steroids and Stomach Ulcers?

Corticosteroids don’t directly cause ulcers the way NSAIDs do. NSAIDs block protective prostaglandins in the stomach lining, leaving it exposed to acid. Steroids? They work differently. They suppress inflammation, slow tissue repair, and can mask pain. So if an ulcer forms - maybe from another cause - steroids might keep you from feeling the warning signs until it’s too late. That’s why complications like bleeding or perforation can sneak up.

A 2014 review in BMJ Open looked at over a million patients. It found that for people taking steroids in outpatient settings - meaning, most of us - there was no significant increase in GI bleeding. But for hospitalized patients? Risk jumped by 43%. Why? Because they’re sicker, often on multiple drugs, and their bodies are under more stress. The real danger isn’t the steroid alone. It’s the combo.

The Big Red Flag: NSAIDs and Steroids Together

If you’re taking both corticosteroids and NSAIDs - like ibuprofen, naproxen, or even low-dose aspirin - your risk of a serious GI event goes up dramatically. One study of Medicaid patients showed a 4.4-fold increase in ulcer complications when these drugs were used together. That’s not a small bump. That’s a red alert.

Here’s the hard truth: if you’re on both, you need protection. PPIs are the go-to. Misoprostol works too, but it causes cramping and diarrhea in many people, so it’s not first-line. The evidence here is solid. Don’t skip this step. If you’re on steroids for a flare-up of rheumatoid arthritis or lupus and you’re also taking ibuprofen for joint pain, you’re playing with fire. Talk to your doctor about switching to acetaminophen or finding another pain control plan.

Why So Many People Get Unnecessary PPIs

A 2022 survey of 347 hospitalists found that nearly 80% routinely prescribed PPIs to patients on high-dose steroids - even when they weren’t taking NSAIDs. But here’s the kicker: 63% of those doctors admitted they didn’t have strong evidence to support it. So why do it? Fear. Tradition. And the belief that it’s "better safe than sorry."

But "better safe" isn’t always better. PPIs aren’t harmless. Long-term use links to vitamin B12 deficiency, low magnesium, increased risk of C. diff infections, and even bone fractures. Taking a PPI when you don’t need it is like using a sledgehammer to crack a nut - you might fix the problem, but you create new ones.

At Johns Hopkins, a quality improvement project stopped routine PPIs for steroid-only patients. Over 12 months, PPI use dropped by 42.7%. And guess what? No rise in ulcers or bleeding. At the University of Wisconsin, they cut inappropriate PPI prescriptions by 35% after introducing a simple protocol: only give PPIs if you’re also on NSAIDs, have a past ulcer, or are hospitalized.

Who Actually Needs Protection?

Not everyone. But some people definitely do. Here’s who should get a PPI or other gastroprotective therapy:

• You’re taking both corticosteroids and NSAIDs
• You have a history of peptic ulcer disease or GI bleeding
• You’re on anticoagulants like warfarin or apixaban
• You’re in the hospital, especially if you’re critically ill
• You’re over 65 and on high-dose steroids (>20mg prednisone daily)

If none of those apply to you, you probably don’t need a PPI. Ask your doctor. If they say "it’s standard," ask them to show you the evidence. The American College of Gastroenterology doesn’t recommend routine prophylaxis for steroid monotherapy. Neither does the American Gastroenterological Association - and they’re reviewing it again in 2025.

Monitoring: What to Watch For

Even if you’re not on a PPI, you still need to monitor. Ulcers don’t always scream. Sometimes they whisper - and by the time you hear it, it’s too late.

Pay attention to these red flags:

• Black, tarry stools (melena)
• Vomiting blood or material that looks like coffee grounds
• Unexplained fatigue or dizziness (signs of anemia from slow bleeding)
• Persistent upper abdominal pain that doesn’t go away with antacids
• Loss of appetite or unexplained weight loss

If you notice any of these, get checked. Don’t wait. Endoscopy is the gold standard for diagnosis - and it’s a quick, safe procedure. Don’t let fear of the test stop you. It’s better than a surprise bleed.

Also, monitor your blood sugar. Steroids cause insulin resistance. Post-meal spikes are more common than fasting highs. If you’re prediabetic or diabetic, your glucose levels may climb even on low doses. Check your levels regularly. Adjust your diet. Talk to your doctor about whether your diabetes meds need tweaking.

What About H. pylori?

Helicobacter pylori is the #1 cause of peptic ulcers worldwide. Steroids don’t cause it - but if you have it, they can make things worse. If you’ve had an ulcer before, or if you’re from a region with high H. pylori rates (like parts of Asia, Eastern Europe, or Latin America), ask your doctor about testing. A simple breath test or stool antigen test can detect it. If positive, treatment with antibiotics and a PPI clears it in most cases - and removes a major risk factor.

The Bottom Line: No One-Size-Fits-All

The old rule - "steroids mean PPIs" - is outdated. It’s not evidence-based. It’s not cost-effective. And it’s potentially harmful.

Here’s what you should do instead:

1. Ask your doctor: "Am I taking NSAIDs?" If yes, you need a PPI.
2. Do you have a history of ulcers or GI bleeding? If yes, you need a PPI.
3. Are you in the hospital? If yes, you likely need a PPI.
4. Are you on high-dose steroids (>20mg prednisone) and over 65? Consider a PPI, but discuss the risks.
5. If none of the above apply? You probably don’t need a PPI. Say no - politely - and ask for the evidence.

And if you’re already on a PPI for steroids alone? Don’t stop cold turkey. Talk to your doctor. They may be able to taper it off safely - especially if you’ve been on it for months or years.

The goal isn’t to avoid all medications. It’s to take only what you need. Steroids save lives. But unnecessary PPIs? They just add clutter to your pillbox - and risk to your health.