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

Most Common 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 Treatment Options

Proton Pump Inhibitors (PPIs)

• Standard therapy involves a 4-8 week course at standard dosing 1
• Examples include:
  • Omeprazole 20 mg daily
  • Lansoprazole 30 mg daily
  • Pantoprazole 40 mg daily
  • Rabeprazole 20 mg daily
• PPIs should be taken 30-60 minutes before meals for optimal effect 1
• PPIs are significantly more effective than H2-receptor antagonists for healing duodenal and gastric ulcers 2

H. pylori Eradication Therapy

• Recommended for all H. pylori-positive patients with peptic disease 1
• Typically consists of a PPI plus appropriate antibiotics 1
• Common regimens include:
  • Bismuth quadruple therapy
  • Rifabutin triple therapy
• Eradication therapy cures the underlying disease and prevents recurrence 1

Second-Line and Adjunctive Treatments

H2 Receptor Antagonists (H2RAs)

• Less effective than PPIs but more effective than placebo 1
• Options include ranitidine, famotidine, and nizatidine
• May be used in patients who cannot tolerate PPIs

Antacids

• Provide direct buffering of gastric acid
• Best for on-demand, immediate relief rather than daily maintenance therapy 1
• Limited evidence for effectiveness when used alone for daily acid reduction

Prokinetic Agents

• May be considered for dysmotility-like symptoms (fullness, bloating) 1
• Less commonly used as primary therapy for peptic disease

Comparative Efficacy

• PPIs are more effective than H2-receptor antagonists in healing duodenal and gastric ulcers 2
• For NSAID-associated gastric ulcers, lansoprazole 30 mg daily demonstrated significantly higher healing rates (79% at 8 weeks) compared to active control (55%) 3
• In erosive esophagitis, lansoprazole 30 mg daily was significantly more effective than ranitidine 150 mg twice daily (92.1% vs 69.9% healing at 8 weeks) 3

Treatment Duration and Maintenance

• For duodenal ulcers: 2-4 weeks of standard PPI therapy 2
• For gastric ulcers: 4-8 weeks of standard PPI therapy 2
• For H. pylori-negative patients or those with persistent symptoms after eradication: continue PPI therapy at standard dose 1
• For maintenance therapy: use the lowest effective PPI dose 1

Common Pitfalls and Considerations

• 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 (not taking 30-60 minutes before meals) 1
• Potential side effects of long-term PPI use include:
  • Headaches, diarrhea, constipation, and nausea (up to 14% of patients) 1
  • Rare reports of vitamin B12 deficiency in elderly patients with prolonged use 1
  • Potential association with increased risk of community-acquired pneumonia 4

Special Considerations

• For patients requiring continuous NSAID therapy, PPIs have been shown to heal a significantly higher percentage of peptic ulcers than H2-receptor antagonists 5
• Pantoprazole is a preferred PPI option for patients on multiple medications due to its lower potential for drug interactions 1
• Regular review of ongoing indications for PPI use is recommended, and de-prescribing should be considered for patients without definitive indications for chronic PPI use 1