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

Most Commonly Used 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

Hierarchy of Medication Options for Peptic Disease

First-Line Therapy: Proton Pump Inhibitors (PPIs)

• PPIs are the primary treatment for peptic disease, with standard therapy involving a 4-8 week course at standard dosing 1
• PPIs are more effective than H2 receptor antagonists (H2RAs), which are in turn more effective than placebo 2, 3
• Common PPI options include:
  • Omeprazole 20mg daily
  • Lansoprazole 30mg daily
  • Pantoprazole 40mg daily
  • Rabeprazole 20mg daily 3

Second-Line Therapy: H. pylori Eradication

• For H. pylori-positive peptic ulcer disease, eradication therapy (PPI + appropriate antibiotics) is recommended as it cures the underlying disease and prevents recurrence 1
• Common regimens include Bismuth quadruple therapy and Rifabutin triple therapy 1
• Testing for H. pylori is recommended in all patients with confirmed peptic disease 1

Third-Line Therapy: H2 Receptor Antagonists (H2RAs)

• H2RAs are less effective than PPIs but more effective than placebo 1
• Options include ranitidine, famotidine, and nizatidine 1
• H2RAs reduce the incidence of duodenal ulcers but are less effective for gastric ulcers 1

Fourth-Line Therapy: Antacids and Prokinetics

• Antacids provide direct buffering of gastric acid, best for on-demand, immediate relief rather than daily maintenance therapy 1
• Prokinetic agents may be considered for dysmotility-like symptoms (fullness, bloating) 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for GERD syndromes 2

Clinical Application Algorithm

1. Initial Management:

   • Begin with PPI therapy (4-8 week course at standard dosing) 1
   • Take PPIs 30-60 minutes before meals to ensure adequate dosing 1

2. If H. pylori positive:

   • Add appropriate antibiotics for eradication therapy 1
   • Continue PPI therapy at standard dose for persistent symptoms after eradication 1

3. If partial response to initial PPI therapy:

   • Consider twice-daily PPI dosing 1
   • For patients with persistent symptoms despite PPI therapy, consider endoscopy 1

4. For maintenance therapy:

   • Use the lowest effective PPI dose 1
   • For refractory cases, reassess diagnosis with endoscopy if not already done 1

Important Considerations and Pitfalls

• Proper PPI dosing: PPIs should be taken 30-60 minutes before meals to ensure adequate acid suppression 1
• Avoiding inappropriate long-term use: Regular review of ongoing indications for PPI use is recommended 1
• Drug interactions: Main concern is with medications metabolized by the CYP450 system, such as clopidogrel 1
• Testing for H. pylori: Failure to test for H. pylori in patients with peptic ulcer disease is a common pitfall 1
• Potential side effects of PPIs: Include headaches, diarrhea, constipation, and nausea (up to 14% of patients) 1

While all options mentioned in the question have roles in peptic disease management, PPIs have emerged as the treatment of choice for acid-related diseases, including GERD and peptic ulcer disease 4. Their superior efficacy in healing rates and symptom relief has made them the most commonly used medication class for this condition.