The most appropriate management is to start standard-dose omeprazole (20 mg/d). The chronic use of NSAIDs is associated with significant gastrointestinal risk. Nearly one in four chronic NSAID users will develop ulcer disease and as many as 4% will have bleeding or perforation complications. Risk factors for NSAID-related gastrointestinal complications include a history of peptic ulcer disease or other gastrointestinal bleeding event; Helicobacter pylori infection; age 65 years or older; concomitant use of aspirin (of any dose), anticoagulants, other NSAIDs, or glucocorticoids; high-dose NSAID use; and chronic comorbid illness. Although this patient is currently tolerating her daily NSAID well, she has several risk factors that put her at increased risk for NSAID-associated gastric injury (age older than 65 years and daily low-dose aspirin for cardiovascular risk reduction). Therefore, the most appropriate strategy for gastric protection is omeprazole, 20 mg/d. Standard-dose daily proton pump inhibitor (PPI) therapy has consistently demonstrated superiority to placebo in significantly reducing the risk of NSAID-induced gastric injury. Higher PPI doses have not demonstrated superiority to standard-dose therapy. If PPI therapy cannot be used, misoprostol, 200 µg four times daily, is an alternative; however, side effects such as abdominal cramps and diarrhea may be limiting.

Changing this patient's aspirin to an enteric-coated formulation will not reduce the risk of NSAID-induced gastrointestinal injury.

Given this patient's risk profile, preventive measures should be pursued. Therefore, continued observation alone on the current medication regimen is not appropriate.