Most Commonly Used Drugs for Peptic Disease
Proton Pump Inhibitors (PPIs) are the most commonly used drugs for peptic disease due to their superior efficacy in acid suppression compared to other medication classes. 1
Evidence Supporting PPIs as First-Line Therapy
PPIs have emerged as the treatment of choice for acid-related disorders including:
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease (PUD)
- H. pylori infection (as part of combination therapy)
- Dyspepsia
The American Gastroenterological Association (AGA) guidelines strongly recommend PPIs for the treatment of esophageal GERD syndromes, noting they are more effective than histamine-2 receptor antagonists (H2RAs), which are in turn more effective than placebo 1.
Prevalence of PPI Use
Recent systematic reviews report PPI use ranging from 4% to 33% of the population in studies from the United States, Europe, and Australia, with most data showing increasing use over time 1.
Comparison of Treatment Options
1. Proton Pump Inhibitors (PPIs)
- Mechanism: Irreversibly inhibit proton pump (H+/K+ ATPase) function
- Examples: Omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, dexlansoprazole
- Efficacy: Most potent gastric acid-suppressing agents available
- Clinical outcomes: Heal >90% of duodenal ulcers after 4 weeks, >90% of gastric ulcers after 6 weeks, and >90% of erosive GERD after 8 weeks 2
2. H. pylori Eradication Therapy
- Always includes PPIs plus antibiotics
- Common regimens:
- Bismuth quadruple therapy (14 days): Bismuth + tetracycline + metronidazole + PPI
- Rifabutin triple therapy (14 days): Rifabutin + amoxicillin + PPI 1
- H. pylori eradication is a specific treatment for H. pylori-associated peptic ulcers, not a general treatment for all peptic disease
3. H2 Receptor Antagonists (H2RAs)
- Examples: Cimetidine, ranitidine, famotidine, nizatidine
- Efficacy: Less effective than PPIs but more effective than placebo 1
- Use: Often used as second-line therapy or for short-term/as-needed use
4. Antacids and Prokinetics
- Antacids: Provide rapid but short-term relief
- Prokinetics: Limited evidence supporting efficacy in peptic disease
- The AGA specifically recommends against metoclopramide as monotherapy or adjunctive therapy for GERD 1
Clinical Considerations for PPI Selection
Different PPIs vary in:
- Potency: Pantoprazole (40 mg = 9 mg omeprazole) is less potent than esomeprazole or rabeprazole 1, 3
- Metabolism: All undergo hepatic metabolism via CYP450 system, primarily CYP2C19 1
- Drug interactions: Omeprazole has highest risk for interactions; rabeprazole and pantoprazole have lowest risk 4
- Onset of action: Rabeprazole has more rapid onset than other PPIs 2
Emerging Alternatives: Potassium-Competitive Acid Blockers (P-CABs)
P-CABs (e.g., vonoprazan, tegoprazan) are a newer class of antisecretory medications that may provide more potent acid inhibition than PPIs 1, 5. However, the AGA recommends against using P-CABs as initial therapy for acid-related conditions in which clinical superiority has not been shown, primarily due to cost and fewer long-term safety data 1.
Common Pitfalls in PPI Use
- Timing of administration: PPIs should be taken 30-60 minutes before meals (except dexlansoprazole) 1
- Duration of therapy: Reassess continued use so that long-term therapy is used judiciously 6
- Genetic variations: CYP2C19 polymorphisms affect metabolism of some PPIs, leading to variability in therapeutic outcomes 1
- Rebound symptoms: Discontinuation of PPIs may result in rebound symptoms requiring further or continuous use 6
In summary, while all four medication classes have roles in treating peptic disease, PPIs remain the most commonly used and most effective first-line therapy for the majority of acid-related disorders.