What is the recommended treatment for peptic ulcers?

Recommended Treatment for Peptic Ulcers

The recommended first-line treatment for peptic ulcers is a combination of proton pump inhibitor (PPI) therapy and H. pylori eradication therapy for H. pylori-positive patients, with standard triple therapy consisting of a PPI, amoxicillin (1000 mg twice daily), and clarithromycin (500 mg twice daily) for 14 days in areas with low clarithromycin resistance. 1

H. pylori Testing and Eradication

• All patients with peptic ulcer disease should undergo H. pylori testing 1

• Available non-invasive tests include:

  • Urea breath test (UBT) - sensitivity 88-95%, specificity 95-100%
  • Stool antigen testing - sensitivity 94%, specificity 92%
  • Endoscopic tissue biopsy for patients with bleeding peptic ulcers

• For H. pylori-positive patients, eradication therapy is strongly recommended to prevent recurrent bleeding 1

• H. pylori eradication reduces ulcer recurrence rates from 50-60% to 0-2% 2

Eradication Regimens

1. First-line therapy (in areas with low clarithromycin resistance):

   • Standard triple therapy for 14 days 1:
     • PPI standard dose twice daily
     • Clarithromycin 500 mg twice daily
     • Amoxicillin 1000 mg twice daily

2. Alternative first-line therapy (in areas with high clarithromycin resistance):

   • Sequential therapy for 10 days 1:
     • PPI standard dose twice daily + Amoxicillin 1000 mg twice daily (first 5 days)
     • PPI standard dose twice daily + Clarithromycin 500 mg twice daily + Metronidazole 500 mg twice daily (next 5 days)

3. Second-line therapy (if first-line therapy fails):

   • Levofloxacin-amoxicillin triple therapy for 10 days 1:
     • PPI standard dose twice daily
     • Levofloxacin 500 mg once daily or 250 mg twice daily
     • Amoxicillin 1000 mg twice daily

PPI Therapy

• For non-bleeding peptic ulcers, PPI therapy can heal 80-100% of ulcers within 4 weeks 2
• Larger gastric ulcers (>2 cm) may require 8 weeks of treatment 2
• For bleeding peptic ulcers, high-dose IV PPI (80 mg bolus followed by 8 mg/h continuous infusion for 72 hours) is recommended after endoscopic therapy 3
• Standard triple therapy should be started after 72-96 hours of intravenous PPI administration 1

Management Based on Etiology

NSAID-Induced Ulcers

• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 2
• If continued NSAID use is necessary:
  • Consider selective COX-2 inhibitors
  • Add PPI for gastroprotection 3

H. pylori-Negative Ulcers

• These ulcers are more aggressive with higher recurrence rates and increased risk of bleeding and perforation 4
• Long-term PPI therapy may be beneficial 4

Monitoring and Follow-up

• Confirm H. pylori eradication 4 weeks after completing therapy 3
• Consider endoscopic follow-up in 8-12 weeks to confirm healing, especially for gastric ulcers to rule out malignancy 3
• Monitor for potential PPI adverse effects with long-term therapy 3:
  • Acute tubulointerstitial nephritis 5, 6
  • Clostridium difficile-associated diarrhea 5, 6
  • Bone fracture risk with long-term use 5, 6
  • Hypomagnesemia 5, 6
  • Vitamin B12 deficiency 5

Management of Complications

Bleeding Ulcers

• Endoscopic hemostatic therapy for active bleeding
• High-dose IV PPI therapy following endoscopic intervention 3
• Mechanical therapy with epinephrine injection for active bleeding 3

Perforated Ulcers

• CT scan imaging is recommended for diagnosis 1
• Surgical intervention may be necessary based on the size of perforation and patient's condition 1

Important Considerations

• Use the lowest effective dose and shortest duration of PPI therapy to minimize adverse effects 5, 6
• The choice of eradication regimen should be based on local antibiotic resistance patterns, particularly clarithromycin resistance 1
• For patients with previous peptic ulcer disease, prevention strategies should focus on appropriate PPI use, H. pylori eradication, and avoiding NSAIDs when possible 3