What medications and dosages would you prescribe for Peptic Ulcer Disease (PUD)?

From the Guidelines

For Peptic Ulcer Disease (PUD), I would prescribe the following medications:

Proton Pump Inhibitors (PPIs)

• Esomeprazole 40mg orally twice daily for 14 days, as recommended by 1
• Alternatively, Lansoprazole 45mg orally twice daily for 14 days, or Pantoprazole 40mg orally twice daily for 14 days, with a minimum dose of 40 mg of omeprazole or equivalent, as suggested by 1

Helicobacter pylori (H. pylori) Eradication

• For H. pylori-positive patients, standard triple therapy is recommended as first-line therapy, consisting of:
  • Amoxicillin 1000mg orally twice daily for 14 days
  • Clarithromycin 500mg orally twice daily for 14 days
  • And, a PPI (as mentioned above) for 14 days, as recommended by 1
• Alternatively, a 10-day levofloxacin-amoxicillin triple therapy can be used as second-line therapy, with doses of:
  • Levofloxacin 500mg orally once daily or 250mg twice daily
  • Amoxicillin 1000mg orally twice daily
  • And, a PPI (as mentioned above) for 10 days, as recommended by 1

Ulcer Protection and Healing

• Sucralfate 1g orally four times daily for 8 weeks, on an empty stomach, can be used for ulcer protection and healing

Antacids for Symptom Relief

• Aluminum hydroxide or Magnesium hydroxide 1-2 tablets orally as needed, not to exceed 8 tablets in 24 hours, can be used for symptom relief It's essential to note that the choice of medication and duration of treatment may vary based on individual patient needs, the presence of H. pylori, and the severity of the ulcer, as well as consideration of NSAID use and CV risk, as discussed in 1. Regular follow-up and monitoring are crucial to adjust the treatment plan as necessary.

From the FDA Drug Label

By Week 8,83% of patients treated with Famotidine had healed DU, compared to 45% of patients treated with placebo. Table 4: Patients with Endoscopically-Confirmed Healed Duodenal Ulcers Famotidine Tablets 40mg at bedtime (N=89) Famotidine Tablets 20mg twice daily (N=84) Placebo at bedtime (N=97) Week 2 32% a 38% a 17% Week 4 70% 67% a 31% ap<0. 001 vs. placebo In this study, time to relief of daytime and nocturnal pain was shorter for patients receiving Famotidine than for patients receiving placebo; patients receiving Famotidine also took less antacid than patients receiving placebo. Table 5: Patients with Endoscopically-Confirmed Healed Gastric Ulcers Famotidine 40mg at bedtime (N-74) Placebo at bedtime (N=75) Famotidine 40mg at bedtime (N=149) Placebo at bedtime (N=145) Week 4 45% 39% 47% a 31% Week 6 66% a 44% 65% a 46% Week 8 78% b 64% 80% a 54% ap≤0.01 vs. placebo bp≤0. 05 vs. placebo Table 7: Patients with Endoscopic Healing of Erosive Esophagitis - U. S. Study (N=318) Famotidine 40mg twice daily (N=127) Famotidine 20mg twice daily (N=125) Placebo twice daily (N=66) Week 6 48% a,b 32% 18% Week 12 69% a,c 54% a 29% ap0.01 vs. placebo bp0.01 vs. Famotidine tablets 20 mg twice daily cp0.05 vs. Famotidine tablets 20 mg twice daily Table 16: Proportion of Patients Remaining Free of Gastric Ulcers* WeekLansoprazole 15 mg daily (N=121) Lansoprazole 30 mg daily (N=116) Misoprostol 200 mcg four times daily (N=106) Placebo (N=112) 4 90%92%96%66% 8 86%88%95%60% 12 80%82%93%51%

• % = Life Table Estimate (p<0. 001) lansoprazole 15 mg daily vs placebo; lansoprazole 30 mg daily vs placebo; and misoprostol 200 mcg four times daily vs placebo.

For Peptic Ulcer Disease (PUD), the following medications and dosages may be prescribed:

• Famotidine: 20mg twice daily or 40mg at bedtime for duodenal ulcers, and 40mg twice daily for gastric ulcers and erosive esophagitis.
• Lansoprazole: 15mg daily or 30mg daily for NSAID-associated gastric ulcers, and 30mg daily for erosive esophagitis. It is essential to note that the choice of medication and dosage may vary depending on the specific condition, patient response, and other factors, and should be determined by a healthcare professional. 2 3

From the Research

Medications for Peptic Ulcer Disease (PUD)

• Antacids: a high-potency liquid antacid given at a dose of from 15 to 30 mL one and three hours after meals and at bedtime for a period of six to eight weeks 4
• H2 receptor blockers:
  • Cimetidine 300 mg with meals and at bedtime 4
  • Ranitidine 150 mg b.i.d. over a six to eight week period 4
• Sucralfate: given one-half hour before meals and at bedtime for a six to eight week period 4
• Proton pump inhibitors (PPI): administered in the morning on an empty stomach in a single daily dose 5
• Anticholinergic agents: may be added before bedtime or one-half hour before meals in patients who are not responding fully to an antacid or H2 blocker regimen 4
• Misoprostol: used to prevent PUD in patients taking NSAIDs 6

Treatment Regimens

• Intensive antacid regimen: a high-potency liquid antacid given at a dose of from 15 to 30 mL one and three hours after meals and at bedtime for a period of six to eight weeks 4
• H2 receptor blocker regimen: cimetidine 300 mg with meals and at bedtime, or ranitidine 150 mg b.i.d. over a six to eight week period 4
• Sucralfate regimen: given one-half hour before meals and at bedtime for a six to eight week period 4
• Standard triple therapy: for H. pylori infection, only recommended when resistance to clarithromycin is low 6
• Sequential therapy, quadruple therapy, and levofloxacin-based triple therapy: alternative treatment options for H. pylori infection 6

Special Considerations

• Patients with NSAID-induced PUD: misoprostol and proton pump inhibitors are recommended for prevention 6
• Patients with H. pylori infection: eradication treatment with antibiotics may reduce recurrent ulcer disease and negate the need for maintenance therapy 7, 8
• Patients with chronic use of NSAIDs: increased risk of PUD, recommended therapies include misoprostol and proton pump inhibitors 6