From the Guidelines
PPI treatment should be continued after H. pylori eradication in patients with gastric ulcers (GU) until complete healing is achieved and in complicated duodenal ulcers (DU) until H. pylori eradication is confirmed. According to the Maastricht IV/Florence Consensus Report 1, in uncomplicated DU, prolonging acid inhibition with PPI is not recommended after Helicobacter pylori treatment, but in GU and complicated DU, prolonging PPI is recommended. The report also states that H. pylori eradication treatment should be started at reintroduction of oral feeding in cases of bleeding ulcer.
The use of PPIs after H. pylori treatment is supported by the fact that they reduce gastric acid production, creating a more favorable environment for ulcer healing and reducing symptoms like pain and discomfort. Common PPI options include omeprazole 20mg daily, esomeprazole 40mg daily, pantoprazole 40mg daily, or lansoprazole 30mg daily. Patients should take PPIs 30-60 minutes before meals for optimal effectiveness.
Key points to consider when treating patients with H. pylori infection include:
- H. pylori eradication is recommended for both DU and GU, as it effectively achieves ulcer healing rates of >90% 1
- Prolonged acid inhibition with PPI is not required after successful H. pylori eradication in uncomplicated DU, but is beneficial in GU and complicated DU 1
- PPI therapy should be continued after eradication treatment in GU until complete healing is achieved and in complicated DU until H. pylori eradication is confirmed 1
- Follow-up testing to confirm eradication and reassessment may be necessary if symptoms persist after completing both H. pylori treatment and the additional PPI course.
It is also important to note that the ACCF/ACG/AHA Expert Consensus Document 1 recommends PPI therapy for the prevention of NSAID-related ulcers, and that PPIs have been shown to be superior to H2RAs and misoprostol in preventing NSAID ulcer recurrence and improving overall symptom control. However, this document does not directly address the use of PPIs after H. pylori treatment.
From the Research
Treatment with PPI after H. pylori Treatment
- The use of proton-pump inhibitors (PPIs) in the management of complicated peptic ulcer disease and upper gastrointestinal tract bleeding is described in 2.
- PPIs are effective in treating peptic ulcer disease, but they are often prescribed beyond the approved duration, as seen in 3.
- Treatment of peptic ulcers in patients who are H. pylori positive should include antimicrobial therapy to eradicate the infection, and PPIs may be used in combination with antibiotics, as mentioned in 2 and 4.
- The proportion of H. pylori-negative ulcers has increased, and long-term therapy with a PPI may be useful in these patients, as stated in 2.
- PPIs have anti-inflammatory actions and can interfere with the host-bacteria interactions, as shown in 5.
PPI Use in H. pylori Infection
- Optimal omeprazole regimens for anti-H. pylori therapy are those that administer the drug at a dosage of 40 mg/day in combination with 2 antibacterial agents, as mentioned in 4.
- PPIs possess antibacterial activity against H. pylori in vitro, and may also exert an anti-inflammatory effect by interfering with the cellular immune response to infection, as described in 5.
- Lansoprazole is the most effective PPI against H. pylori, although its bactericidal activity is similar to that of omeprazole, as stated in 5.
PPI Treatment Duration
- PPIs are often prescribed beyond the approved eight-week treatment duration for peptic ulcer disease, as seen in 3.
- Patient, provider, and facility factors can influence PPI prescribing, and markers of patient complexity and medication use not meeting gastroprotection guidelines are associated with inappropriate PPI persistence, as mentioned in 3.