What are the most commonly used drugs for peptic disease?

Most Commonly Used Drugs for Peptic Disease

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

First-Line Therapy: Proton Pump Inhibitors

PPIs are the cornerstone of peptic disease management for several reasons:

• They provide superior acid suppression compared to other medications
• Standard therapy involves a 4-8 week course at standard dosing 1
• PPIs heal 80-100% of peptic ulcers within 4 weeks 2
• They are highly effective for both gastric and duodenal ulcers 3

Common PPI options include:

• Omeprazole 20mg daily
• Lansoprazole 30mg daily
• Pantoprazole 40mg daily
• Rabeprazole 20mg daily

For NSAID-associated gastric ulcers, lansoprazole 30mg daily has been shown to be significantly more effective than active control, with healing rates of 77-79% at 8 weeks 4.

Second-Line Therapy: H. pylori Eradication

H. pylori eradication therapy is essential when the bacterium is detected:

• H. pylori affects approximately 42% of patients with peptic ulcer disease 2
• Eradication therapy consists of PPI + appropriate antibiotics 1
• Successful eradication decreases peptic ulcer recurrence rates from 50-60% to 0-2% 2
• Common regimens include bismuth quadruple therapy and rifabutin triple therapy 1

Third-Line Therapy: H2 Receptor Antagonists

H2 receptor antagonists (H2RAs) are less effective than PPIs but more effective than placebo:

• Options include ranitidine, famotidine, and nizatidine 1
• They reduce the incidence of duodenal ulcers but are less effective for gastric ulcers 5
• In comparative studies, PPIs have shown improved efficacy over H2RAs in acid-related disorders 3

Fourth-Line Therapy: Antacids and Prokinetics

Antacids and prokinetics play a more limited role:

• Antacids provide direct buffering of gastric acid, best for on-demand immediate relief rather than daily maintenance therapy 1
• Prokinetics may be considered for dysmotility-like symptoms (fullness, bloating) 1
• These agents are generally considered adjunctive rather than primary therapy

Clinical Decision Algorithm

1. Initial Approach: Start with PPI therapy (4-8 week course)

   • For patients without alarm symptoms, begin with standard PPI dose
   • For patients with alarm symptoms or >45-55 years, consider endoscopy first

2. Test for H. pylori in all patients with confirmed peptic disease

   • If positive, initiate eradication therapy (PPI + appropriate antibiotics)
   • If negative, continue PPI therapy at standard dose

3. Assess Response:

   • If complete response, taper to lowest effective PPI dose
   • If partial response, consider twice-daily PPI dosing
   • If no response, reassess diagnosis with endoscopy

4. For Persistent Symptoms:

   • Consider adding H2RAs as adjunctive therapy
   • Antacids can be used for breakthrough symptoms
   • Prokinetics may help with associated dysmotility symptoms

Common Pitfalls in Management

• Failure to test for H. pylori in patients with peptic ulcer disease 1
• Inappropriate long-term PPI use without periodic reassessment 1
• Inadequate PPI dosing or timing (PPIs should be taken 30-60 minutes before meals) 5
• Not considering drug interactions with PPIs, particularly with medications metabolized by the CYP450 system 1

In conclusion, while all four medication classes have roles in peptic disease management, PPIs remain the most commonly used and most effective first-line therapy, followed by H. pylori eradication when indicated, with H2 blockers and antacids/prokinetics serving as adjunctive or alternative treatments.