What are the medications for bleeding peptic (gastric or duodenal) ulcers?

From the Guidelines

Medications for bleeding peptic ulcers include proton pump inhibitors (PPIs) like omeprazole, which are the first-line treatment to reduce stomach acid and promote clotting, as supported by the most recent study from 2024 1. The treatment of bleeding peptic ulcers involves the use of PPIs, such as omeprazole, to reduce stomach acid and promote clotting.

• The initial treatment typically involves an IV bolus of omeprazole (80 mg) followed by a continuous infusion of 8 mg/hour for 72 hours, as recommended by the study from 2002 1.
• After initial IV therapy, patients typically transition to oral PPIs (40mg twice daily) for 4-8 weeks.
• For H. pylori-associated ulcers, triple therapy is essential: a PPI plus two antibiotics (clarithromycin 500mg twice daily and amoxicillin 1g twice daily or metronidazole 500mg twice daily) for 10-14 days, as recommended by the study from 2020 1.
• Patients should discontinue NSAIDs, smoking, and alcohol consumption.
• Antacids (aluminum/magnesium hydroxide) can provide symptomatic relief between PPI doses.
• H2 receptor antagonists like famotidine (20mg twice daily) may be used as adjuncts but are less effective than PPIs.
• Sucralfate (1g four times daily) can provide additional mucosal protection.
• PPIs work by irreversibly inhibiting the hydrogen-potassium ATPase enzyme in gastric parietal cells, dramatically reducing acid production, which allows the ulcer to heal and prevents further bleeding by maintaining a higher gastric pH that stabilizes blood clots. However, the most recent study from 2024 1 suggests that potassium-competitive acid blockers (P-CABs) may be noninferior to PPIs for secondary peptic ulcer prophylaxis, but do not support their routine use as first-line prophylactic therapy. It is also worth noting that the study from 2020 1 recommends PPI for 6–8 weeks following endoscopic treatment of peptic ulcer bleeding to allow mucosal healing, and that long-term PPI is not recommended unless the patient has ongoing NSAID use. The use of P-CABs for ulcer bleeding is still being studied, and the current evidence is insufficient to support their use as first-line therapy in this population, as stated in the study from 2024 1.

From the FDA Drug Label

14.1 Active Duodenal Ulcer 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).

14.2 H. pylori Eradication in Patients with Duodenal Ulcer Disease Triple Therapy (omeprazole/clarithromycin/amoxicillin)

The medications for bleeding peptic (gastric or duodenal) ulcers include:

• Omeprazole: for the treatment of active duodenal ulcers
• Triple Therapy: omeprazole, clarithromycin, and amoxicillin for H. pylori eradication in patients with duodenal ulcer disease
• Dual Therapy: omeprazole and clarithromycin for the treatment of active duodenal ulcers associated with H. pylori 2

From the Research

Medications for Bleeding Peptic Ulcers

The primary medications used to treat bleeding peptic ulcers include:

• Proton pump inhibitors (PPIs) such as omeprazole, esomeprazole, and pantoprazole 3, 4, 5, 6
• These medications work by reducing the amount of acid produced in the stomach, which helps to promote healing and prevent further bleeding

Dosage and Administration

The dosage and administration of PPIs for bleeding peptic ulcers may vary depending on the specific medication and the patient's condition:

• High-dose omeprazole (80 mg bolus injection, followed by 8 mg/h continuous infusion for 72 h) has been shown to reduce recurrent bleeding and improve outcomes in patients with high-risk peptic ulcer bleeding 3, 6
• Pantoprazole infusion (80 mg intravenous bolus, followed by 8 mg/h continuous infusion for 72 h) has also been shown to be effective in reducing rebleeding and improving outcomes in patients with bleeding peptic ulcers 5
• The optimal dosage and duration of PPI therapy may depend on the patient's individual needs and response to treatment 4, 7

Clinical Benefits and Limits

The use of PPIs in the treatment of bleeding peptic ulcers has several clinical benefits, including:

• Reduced risk of recurrent bleeding 3, 4, 5, 6
• Decreased need for transfusions and surgery 5, 6
• Improved outcomes and reduced mortality 3, 6
• However, the use of PPIs may also have limitations, such as inter-patient variability in response to treatment and the potential for adverse effects 4, 7