What is the treatment for duodenal ulcer or gastritis-related abdominal pain?

From the Guidelines

Treatment of duodenal ulcer or gastritis pain should prioritize proton pump inhibitors (PPIs) as the first-line therapy, given their effectiveness in reducing acid production and promoting healing, as supported by the most recent evidence 1. When managing duodenal ulcer or gastritis pain, it's essential to consider the underlying cause and tailor treatment accordingly. For immediate pain relief, antacids like Maalox or Mylanta can be taken as needed.

• H2 blockers such as famotidine (20mg twice daily) or ranitidine (150mg twice daily) reduce acid production and provide relief within hours.
• PPIs like omeprazole (20mg daily) or pantoprazole (40mg daily) offer stronger acid suppression and are usually continued for 4-8 weeks. If H. pylori infection is present, triple therapy is recommended: a PPI plus two antibiotics (typically amoxicillin 1g twice daily and clarithromycin 500mg twice daily) for 10-14 days, as supported by the Maastricht IV/Florence Consensus Report 1. Patients should avoid NSAIDs, alcohol, smoking, and spicy foods that can worsen symptoms.
• Eating smaller, more frequent meals and elevating the head while sleeping can help reduce acid reflux.
• Stress management is also beneficial as stress can increase stomach acid production. Potassium-competitive acid blockers (P-CABs) may be useful in PPI treatment failures or for secondary ulcer prophylaxis, but their use as first-line therapy is not recommended due to higher costs and limited availability 1. Overall, the goal of treatment is to promote healing, prevent recurrence, and improve quality of life, with PPIs being the preferred initial treatment option.

From the FDA Drug Label

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). Complete daytime and nighttime pain relief occurred significantly faster (p ≤ 0.01) in patients treated with omeprazole 20 mg than in patients treated with placebo. In a multicenter, double-blind study of 293 patients with endoscopically documented duodenal ulcer, the percentage of patients healed (per protocol) at 4 weeks was significantly higher with omeprazole 20 mg once daily than with ranitidine 150 mg b.i.d. (p < 0.01). Lansoprazole delayed-release capsules are indicated in adults for short-term treatment (for four weeks ) for healing and symptom relief of active duodenal ulcer [see Clinical Studies ( 14.1]. Ranitidine has been found to be effective as maintenance therapy for patients following healing of acute duodenal ulcers In a multicenter, double-blind, controlled, US study of endoscopically diagnosed duodenal ulcers; earlier healing was seen in the patients treated with ranitidine as shown in Table 3.

Treatment Options:

• Omeprazole (PO): 20 mg once daily for 4 weeks for healing and symptom relief of active duodenal ulcer 2
• Lansoprazole (PO): short-term treatment (for four weeks ) for healing and symptom relief of active duodenal ulcer 3
• Ranitidine (PO): 150 mg twice daily for healing of duodenal ulcers, and as maintenance therapy for patients following healing of acute duodenal ulcers 4

Key Points:

• Omeprazole and lansoprazole are effective for short-term treatment of active duodenal ulcer
• Ranitidine is effective for healing of duodenal ulcers and as maintenance therapy
• All three medications have been shown to provide symptom relief and healing of duodenal ulcers in clinical studies 2, 3, 4

From the Research

Treatment Options for Duodenal Ulcer or Gastritis Pain

• The treatment of duodenal ulcer or gastritis pain typically involves the use of proton pump inhibitors (PPIs) to reduce gastric acid secretion 5, 6, 7, 8.
• Rabeprazole, a PPI, has been shown to be effective in healing duodenal ulcers and relieving symptoms, with a faster onset of action compared to omeprazole 5.
• Lansoprazole, another PPI, has been found to be more effective than H2-receptor antagonists in relieving ulcer pain and healing gastric and duodenal ulcers 6.
• Omeprazole, a well-studied PPI, is effective in eradicating Helicobacter pylori infection, treating gastro-oesophageal reflux disease (GORD), and preventing NSAID-induced gastrointestinal damage 7.
• A network meta-analysis found that all PPIs (omeprazole, pantoprazole, lansoprazole, rabeprazole, and ilaprazole) significantly increased the 4-week ulcer healing rate compared to H2 receptor antagonists and placebo, with no significant difference among PPIs 8.

Helicobacter pylori Eradication

• Eradication of Helicobacter pylori infection is important in the treatment of gastric or duodenal ulcer, as it improves healing and prevents complications and recurrences 9.
• A combination of a high-dose PPI (such as omeprazole) and antibiotics (such as amoxicillin, clarithromycin, and metronidazole) is commonly used to eradicate H. pylori infection 9, 7.
• The choice of antibiotics may depend on the presence of resistance, with amoxicillin, clarithromycin, and metronidazole being commonly used 9.

Cost-Effectiveness Analysis

• A cost-effectiveness analysis found that pantoprazole (40 mg/day) was the most cost-effective option for the initial non-eradication treatment of duodenal ulcer in China, compared to other PPIs 8.