What is the management of duodenal ulcer (DU)?

From the Guidelines

The management of duodenal ulcer (DU) should prioritize Helicobacter pylori eradication and proton pump inhibitor (PPI) therapy to reduce gastric acid production and promote ulcer healing, as supported by the most recent evidence 1. The first-line treatment typically includes PPIs such as omeprazole 20mg daily, pantoprazole 40mg daily, or esomeprazole 40mg daily for 4-8 weeks.

• If Helicobacter pylori infection is present, eradication therapy is essential and consists of triple therapy: a PPI plus two antibiotics (clarithromycin 500mg twice daily and amoxicillin 1g twice daily, or metronidazole 500mg twice daily if penicillin-allergic) for 10-14 days, as recommended by previous guidelines 1.
• For NSAID-induced ulcers, the offending drug should be discontinued if possible and replaced with acetaminophen or a COX-2 inhibitor.
• Patients should avoid ulcerogenic factors including smoking, alcohol, caffeine, and spicy foods.
• Antacids can provide symptomatic relief but don't promote healing.
• H2-receptor antagonists like ranitidine 150mg twice daily are alternative options if PPIs aren't tolerated.
• Sucralfate 1g four times daily may be used as adjunctive therapy.
• Surgical intervention is rarely needed but may be considered for complications such as perforation, obstruction, or refractory bleeding. The effectiveness of acid suppression therapy stems from its ability to create an environment conducive to mucosal healing by neutralizing the corrosive effect of acid on damaged tissue, while H. pylori eradication removes a major causative factor that impairs mucosal defense mechanisms and stimulates acid production. Recent studies have also explored the use of potassium-competitive acid blockers (P-CABs) in the management of PUD, but their high cost and limited availability make them less suitable as first-line therapy 1. However, P-CABs may be useful in PPI treatment failures of ulcers, assuming such ulcers are not secondary to processes that can cause ulcers even without acid. Further research is needed to fully understand the role of P-CABs in the management of DU.

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). Treatment of Active Duodenal Ulcer % of Patients Healed Omeprazole 20 mg a. m. (n = 99) Placebo a.m. (n = 48) Week 2 41% 13% Week 4 75% 27% 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). Triple Therapy (omeprazole/clarithromycin/amoxicillin)

The management of duodenal ulcer (DU) includes treatment with omeprazole 20 mg once daily, which has been shown to be effective in healing duodenal ulcers and providing pain relief.

• Omeprazole has been compared to ranitidine and placebo in clinical studies, and has been found to be superior in terms of healing rates and pain relief.
• Triple therapy with omeprazole, clarithromycin, and amoxicillin is also effective in eradicating H. pylori infection and healing duodenal ulcers 2.

From the Research

Management of Duodenal Ulcer (DU)

The management of duodenal ulcer (DU) involves the use of medications that reduce stomach acid production, as well as treatments that target the underlying cause of the ulcer, such as Helicobacter pylori (H. pylori) infection.

• The primary goal of treatment is to heal the ulcer, prevent recurrence, and manage symptoms.
• Proton pump inhibitors (PPIs) are the most potent gastric acid-suppressing agents and are commonly used to treat DU 3.
• PPIs, such as omeprazole, lansoprazole, pantoprazole, and rabeprazole, have been shown to be more effective than H2-receptor antagonists in healing duodenal and gastric ulcers 3, 4.
• For H. pylori-positive duodenal ulceration, a combination of a PPI and two antibacterials can eradicate H. pylori in over 90% of cases and significantly reduce ulcer recurrence 3, 5.
• The choice of antibiotics may depend on the presence of antibiotic resistance, and treatment regimens may include amoxicillin, clarithromycin, metronidazole, and others 6.

Treatment Regimens

• A typical treatment regimen for DU may include:
  • A PPI, such as omeprazole 20 mg/day, for 2 to 4 weeks 3.
  • A combination of a PPI and two antibacterials, such as amoxicillin and clarithromycin, for 7 to 14 days 5, 6.
• The treatment regimen may be adjusted based on the presence of H. pylori infection, antibiotic resistance, and other factors.
• Sequential treatment with amoxicillin for 5 days, followed by clarithromycin + metronidazole for 5 days, has also been shown to be effective in eradicating H. pylori 6.

Monitoring and Follow-up

• Patients with DU should be monitored for symptom relief, ulcer healing, and potential side effects of treatment.
• Follow-up endoscopy may be necessary to confirm ulcer healing and rule out complications.
• Patients with H. pylori infection should be tested for eradication of the infection after completion of treatment 6.