What is the management of Peptic Ulcer Disease (PUD)?

From the Guidelines

Management of peptic ulcer disease (PUD) involves a combination of medication therapy and lifestyle modifications, with the primary treatment being eradication of Helicobacter pylori infection if present, using triple therapy consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, amoxicillin 1g twice daily, and clarithromycin 500mg twice daily for 14 days, as recommended by the most recent guidelines 1. The treatment approach for PUD can be broken down into several key components:

• Eradication of H. pylori infection if present, using triple therapy consisting of a PPI, amoxicillin, and clarithromycin for 14 days 1
• PPI therapy alone for 4-8 weeks for NSAID-induced ulcers or if H. pylori is not present 1
• Discontinuation of the offending agent for NSAID-induced ulcers
• Lifestyle modifications, including avoidance of alcohol, tobacco, and spicy foods that may exacerbate symptoms
• Antacids can provide symptomatic relief but don't promote healing, while H2 receptor antagonists like ranitidine 150mg twice daily are alternatives but less effective than PPIs 1
• Sucralfate 1g four times daily can be used as adjunctive therapy
• Surgical intervention is reserved for complications such as perforation, obstruction, or refractory bleeding It's also important to note that potassium-competitive acid blockers (P-CABs) may be useful in PPI treatment failures of ulcers, but are not recommended as first-line therapy for patients with PUD due to higher costs and limited availability 1. In terms of specific treatment regimens, the following are recommended:
• Standard triple therapy (amoxicillin, clarithromycin, and PPI) regimen is recommended as first-line therapy if low clarithromycin resistance is present 1
• 10 days of sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) is recommended in selected cases, if compliance to the scheduled regimen can be maintained, and if clarithromycin high resistance is detected 1
• A 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy if first-line therapy failed 1

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).

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).

The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori.

The management of peptic ulcer disease (PUD) with omeprazole involves:

• Treatment of Active Duodenal Ulcer: omeprazole 20 mg once daily for 4 weeks
• H. pylori Eradication:
  • Triple Therapy: omeprazole 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days
  • Dual Therapy: omeprazole 40 mg once daily plus clarithromycin 500 mg three times daily for 14 days, followed by omeprazole 20 mg once daily for an additional 14 days 2

From the Research

Management of Peptic Ulcer Disease

• The management of peptic ulcer disease (PUD) involves the use of acid blockers, such as omeprazole, which can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks 3.
• Eradication of H. pylori decreases peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2% 3.
• Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9% 3.
• When discontinuing an NSAID is not desirable, changing the NSAID, adding a proton pump inhibitor, and eradicating H. pylori can reduce recurrence rates 3.

Treatment Options

• Proton pump inhibitors (PPIs) are the primary treatment for peptic ulcer disease, with omeprazole being a well-studied and well-tolerated agent effective in adults or children as a component in regimens aimed at eradicating H. pylori infections or as monotherapy in the treatment and prophylaxis of gastro-oesophageal reflux disease (GORD) with or without oesophagitis or NSAID-induced gastrointestinal damage 4.
• Histamine-2 receptor antagonists (H2RAs) are also available, but PPIs are generally considered more effective in healing ulcers and bringing pain relief 5.
• Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy 6.

Prevention of Recurrence

• Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers, and algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in the guidelines 6.
• In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended, and the administration of VPZ is suggested for the prevention of ulcer recurrence 6.
• In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended, and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence 6.