What is the next best step for managing Peptic Ulcer Disease (PUD)?

From the Guidelines

The next best step for managing Peptic Ulcer Disease (PUD) is to initiate a proton pump inhibitor (PPI) such as omeprazole 20mg or pantoprazole 40mg once daily for 4-8 weeks, along with testing for and treating Helicobacter pylori infection if present. For H. pylori eradication, a 14-day triple therapy regimen is recommended, consisting of a PPI twice daily plus amoxicillin 1g twice daily and clarithromycin 500mg twice daily (or metronidazole 500mg twice daily if clarithromycin resistance is suspected) 1. Patients should avoid NSAIDs, alcohol, smoking, and spicy foods that may exacerbate symptoms. After completing treatment, patients with complicated ulcers (bleeding, perforation) or persistent symptoms should undergo follow-up endoscopy to confirm healing. This approach is effective because PPIs reduce gastric acid production, allowing the ulcer to heal, while eradicating H. pylori removes the primary cause of most ulcers. For pain management during healing, antacids may provide temporary relief, but addressing the underlying causes through acid suppression and H. pylori eradication is essential for long-term resolution. It's worth noting that recent studies have also explored the use of potassium-competitive acid blockers (P-CABs) in the management of PUD, but they are not recommended as first-line therapy due to higher costs and limited availability 1. However, P-CABs may be useful in PPI treatment failures or for secondary ulcer prophylaxis in patients at risk for ulcer recurrence. Testing for H. pylori infection and receiving eradication therapy if infection is present is also crucial, as post-treatment H. pylori infection status has been shown to be an independent predictor of rebleeding 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Best Step for Managing Peptic Ulcer Disease (PUD)

The next best step for managing PUD involves a combination of diagnostic procedures, medication, and lifestyle changes.

• Diagnosis: Endoscopy is used to definitively diagnose PUD 2.
• Medication:
  • Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks 2.
  • Proton pump inhibitors (PPIs) are the most potent gastric acid-suppressing agents and are effective in healing duodenal and gastric ulcers 3.
  • Eradication of H. pylori with a combination of a PPI and 2 antibacterials can eradicate H. pylori in over 90% of cases and significantly reduce ulcer recurrence 3, 4.
• Lifestyle changes:
  • Discontinuing NSAIDs can heal 95% of ulcers identified on endoscopy and reduce recurrence from 40% to 9% 2.
  • Avoiding aspirin or NSAIDs if applicable can prevent recurrence of ulcers 2.

Treatment of Complicated PUD

For patients with complicated PUD, such as bleeding or perforation, treatment with PPIs and endoscopic therapy can prevent recurrent bleeding 5.

• Intravenous PPIs can prevent recurrent bleeding after successful endoscopic therapy 5.
• A combination of a PPI and antimicrobial therapy can eradicate H. pylori and reduce ulcer recurrence 4.

Prevention of Recurrence

To prevent recurrence of PUD, it is essential to:

• Eradicate H. pylori if present 2, 3, 4.
• Discontinue aspirin or NSAIDs if applicable 2.
• Use PPIs for long-term therapy in patients with H. pylori-negative ulcers or those who require continuous NSAID therapy 4.