What is the treatment for peptic ulcer disease (PUD)?

From the Guidelines

The treatment for peptic ulcer disease should involve eliminating the underlying cause and reducing stomach acid, with proton pump inhibitors (PPIs) being the cornerstone of treatment, as they reduce acid production and allow the ulcer to heal, as recommended by the most recent guidelines 1.

Causes and Treatment Approaches

The approach to treating peptic ulcer disease (PUD) depends on its cause, which can be Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs (NSAIDs), or other factors.

• For H. pylori-related ulcers, triple therapy consisting of two antibiotics (such as amoxicillin 1g twice daily and clarithromycin 500mg twice daily) plus a PPI (like omeprazole 20mg twice daily) for 10-14 days is the standard approach 1.
• For NSAID-induced ulcers, discontinuing the offending medication and taking a PPI is recommended, with PPIs such as omeprazole 20mg daily, pantoprazole 40mg daily, or esomeprazole 40mg daily being effective options 1.

Treatment Duration and Lifestyle Modifications

• Treatment typically continues for 4-8 weeks for duodenal ulcers and 8-12 weeks for gastric ulcers.
• Patients should avoid irritants like alcohol, smoking, and NSAIDs during healing.
• Antacids may provide temporary symptom relief but are not primary treatments.
• Surgery is rarely needed except for complications like perforation, obstruction, or uncontrolled bleeding.

Mechanism of Action of PPIs

PPIs work by blocking the hydrogen-potassium ATPase enzyme system in gastric parietal cells, effectively shutting down acid production and creating an environment where ulcers can heal 1.

Alternative Treatments

H2 blockers like famotidine 20mg twice daily can be used as alternatives to PPIs, but PPIs are generally more effective in reducing acid production and promoting ulcer healing 1.

From the FDA Drug Label

14.1 Active Duodenal Ulcer In a multicenter, double-blind, placebo-controlled study of 147 patients with endoscopically documented duodenal ulcer, the percentage of patients healed (per protocol) at 2 and 4 weeks was significantly higher with omeprazole 20 mg once daily than with placebo (p ≤ 0.01). 14.2 H. pylori Eradication in Patients with Duodenal Ulcer Disease Triple Therapy (omeprazole/clarithromycin/amoxicillin) INDICATIONS AND USAGE Ranitidine tablets USP are indicated in: 1. Short-term treatment of active duodenal ulcer. Most patients heal within 4 weeks.

The treatment for peptic ulcer disease includes:

• Omeprazole 20 mg once daily for the healing of active duodenal ulcers, as it has been shown to be effective in clinical studies 2
• Triple therapy with omeprazole, clarithromycin, and amoxicillin for the eradication of H. pylori in patients with duodenal ulcer disease 2
• Ranitidine 150 mg twice daily for the short-term treatment of active duodenal ulcer, with most patients healing within 4 weeks 3 It is also recommended to give concomitant antacids as needed for pain relief to patients with active duodenal ulcer 3

From the Research

Treatment Options for Peptic Ulcer Disease

• The primary treatment for peptic ulcer disease is acid blocking with proton pump inhibitors, such as omeprazole or lansoprazole 4.
• Acid blockers can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks, but gastric ulcers larger than 2 cm may require 8 weeks of treatment 4.
• Eradication of H. pylori decreases peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2% 4.
• Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9% 4.

Role of Proton Pump Inhibitors

• Proton pump inhibitors, such as lansoprazole and omeprazole, are effective in the treatment of duodenal ulcers, gastric ulcers, peptic ulcer disease involving H. pylori infection, recurrent ulcers, ulcers induced by nonsteroidal anti-inflammatory drugs, reflux esophagitis, Barrett esophagus, and Zollinger-Ellison syndrome 5, 6.
• Lansoprazole and omeprazole have similar adverse-effect profiles and are well tolerated in both long- and short-term therapy 6.
• The endoscopic healing rate of gastric ulcers after 8 weeks of treatment with lansoprazole was 94.2%, and the endoscopic healing rate of duodenal ulcers after 6 weeks of treatment was 96.2% 7.

Management of Complicated Peptic Ulcer Disease

• The use of proton-pump inhibitors in the management of complicated peptic ulcer disease and upper gastrointestinal bleeding is described 8.
• Treatment of peptic ulcers in patients who are H. pylori positive should include antimicrobial therapy to eradicate the infection 8.
• Long-term therapy with a proton-pump inhibitor may be useful in patients with H. pylori-negative ulcers, which are more aggressive and characterized by high recurrence rates and increased risk of bleeding and perforation 8.