What are the most commonly used drugs for managing peptic disease?

Most Common Drugs for Peptic Disease Management

Proton pump inhibitors (PPIs) are the most commonly used drugs for managing peptic disease due to their superior efficacy in acid suppression and excellent safety profile. 1, 2

First-Line Pharmacological Treatment Options

1. Proton Pump Inhibitors (PPIs)

• Primary recommendation for most forms of peptic disease
• Standard therapy involves 4-8 week course at standard dosing 1, 2
• Options include:
  • Omeprazole (20mg daily)
  • Lansoprazole (30mg daily)
  • Esomeprazole (40mg daily)
  • Rabeprazole (20mg daily)
  • Pantoprazole (40mg daily)
  • Dexlansoprazole (30-60mg daily)
• Should be taken 30-60 minutes before meals 1
• After adequate response, taper to lowest effective dose 1, 2

2. H. pylori Eradication Therapy

• Essential for H. pylori-positive peptic ulcer disease 1, 2
• Typically includes PPI plus antibiotics (e.g., clarithromycin, amoxicillin)
• Cures underlying peptic ulcer disease and prevents recurrence 1
• Strong recommendation with high-quality evidence 1, 2

3. H2 Receptor Antagonists (H2RAs)

• Less effective than PPIs but still useful in certain scenarios 1, 2
• Options include famotidine, ranitidine, nizatidine
• May be used as alternative when PPIs are contraindicated 2

4. Antacids and Prokinetics

• Antacids provide immediate symptom relief but not suitable for long-term management 2
• Prokinetics (e.g., metoclopramide) may help with dysmotility symptoms 1, 2
• Less commonly used as primary therapy 1

Treatment Algorithm

1. Initial Assessment:

   • For patients without alarm symptoms: Begin with PPI trial (4-8 weeks) 1
   • For patients with alarm symptoms or >45-55 years: Endoscopy first 1
   • Test for H. pylori in all patients with confirmed peptic disease 1, 2

2. If H. pylori positive:

   • Eradication therapy (PPI + appropriate antibiotics) 1, 2
   • Reassess symptoms after completion

3. If H. pylori negative or symptoms persist after eradication:

   • Continue PPI therapy at standard dose 1, 2
   • If partial response: Consider twice-daily PPI dosing 1, 2

4. For maintenance therapy:

   • Use lowest effective PPI dose 1, 2
   • Consider on-demand therapy for milder cases 2

5. For refractory cases:

   • Reassess diagnosis with endoscopy if not already done 1
   • Consider alternative medications (H2RAs, prokinetics) 1, 2
   • For functional dyspepsia: Consider tricyclic antidepressants 1

Important Clinical Considerations

• Long-term PPI use is generally safe but should be at the lowest effective dose 2, 3
• Regular reassessment of ongoing PPI indication is recommended 2
• PPIs are more effective than H2RAs for healing erosive disease 4, 5
• Pantoprazole may be preferred in patients on multiple medications due to fewer drug interactions 2
• Potential PPI side effects include headache, diarrhea, and rarely vitamin B12 deficiency in elderly with prolonged use 1, 3

Common Pitfalls to Avoid

1. Failure to test for H. pylori in patients with peptic ulcer disease
2. Inappropriate long-term PPI use without periodic reassessment
3. Inadequate PPI dosing (not taking 30-60 minutes before meals)
4. Missing non-acid related causes of persistent symptoms
5. Not considering drug interactions with PPIs, particularly with medications metabolized by CYP450 system 2

In summary, while all four medication classes mentioned have roles in peptic disease management, PPIs remain the cornerstone of therapy due to their superior efficacy in acid suppression, followed by H. pylori eradication therapy when indicated, with H2RAs and antacids/prokinetics serving more supplementary or alternative roles.