What is the recommended treatment for peptic ulcers?

Recommended Treatment for Peptic Ulcers

The recommended first-line treatment for peptic ulcers is a proton pump inhibitor (PPI) plus H. pylori eradication therapy for H. pylori-positive patients, with standard triple therapy consisting of a PPI, clarithromycin 500mg, and amoxicillin 1000mg, each twice daily for 14 days. 1, 2

Diagnostic Approach

• CT scan is recommended for suspected perforated peptic ulcer (strong recommendation)
• If CT is unavailable, chest/abdominal X-ray is recommended as initial assessment
• Endoscopy is the definitive diagnostic tool for confirming peptic ulcer disease
• Testing for H. pylori infection is essential in all peptic ulcer patients

Treatment Algorithm

Step 1: Initial PPI Therapy

• Standard dose PPI once daily for 4-8 weeks for uncomplicated peptic ulcers 2
  • Omeprazole 20mg daily
  • Lansoprazole 30mg daily
  • Pantoprazole 40mg daily
  • Rabeprazole 20mg daily
  • Esomeprazole 20mg daily
• For larger gastric ulcers (>2cm), extend treatment to 8 weeks 2, 3

Step 2: H. pylori Testing and Eradication

• Test all peptic ulcer patients for H. pylori infection
• For H. pylori positive patients, initiate eradication therapy 1, 2:

First-line H. pylori eradication (areas with low clarithromycin resistance):

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

Alternative regimen (areas with high clarithromycin resistance):

• Sequential Therapy (10 days):
  • Days 1-5: PPI standard dose twice daily + Amoxicillin 1000mg twice daily
  • Days 6-10: PPI standard dose twice daily + Clarithromycin 500mg twice daily + Metronidazole 500mg twice daily 1

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

• Levofloxacin-based Triple Therapy (10 days):
  • PPI standard dose twice daily
  • Levofloxacin 500mg once daily or 250mg twice daily
  • Amoxicillin 1000mg twice daily 1

Step 3: Management of Bleeding Peptic Ulcers

• High-dose PPI therapy:
  • Initial IV therapy: 80mg bolus followed by 8mg/h continuous infusion for 72 hours
  • Followed by oral therapy: 40mg twice daily for 6-8 weeks 2
• Start standard triple therapy for H. pylori eradication after 72-96 hours of IV PPI administration 1

Special Considerations

NSAID-Associated Ulcers

• Discontinue NSAIDs when possible (heals 95% of ulcers) 3
• If NSAIDs must be continued:
  • Switch to less gastrotoxic NSAID
  • Add PPI therapy
  • Eradicate H. pylori if present 3

Antiplatelet Therapy Management

• For patients on dual antiplatelet therapy who experience bleeding:
  • Consult with a cardiologist before discontinuing any antiplatelet agent
  • Continue aspirin and temporarily withhold P2Y12 inhibitor (e.g., clopidogrel)
  • Resume P2Y12 inhibitor preferably within 5 days after endoscopic hemostasis 2

Refractory Ulcers

• For ulcers resistant to standard PPI therapy, consider:
  • Increasing PPI dose (up to 40mg twice daily) 4, 5
  • Confirming patient compliance
  • Re-evaluating for H. pylori infection
  • Investigating other causes (Zollinger-Ellison syndrome, malignancy)

Follow-Up and Monitoring

• Confirm H. pylori eradication 4 weeks after completing therapy
• Consider endoscopic follow-up in 8-12 weeks for gastric ulcers to confirm healing and rule out malignancy 2
• Monitor for potential adverse effects of long-term PPI use:
  • Vitamin B12 deficiency 6, 7
  • Hypomagnesemia 6, 7
  • Increased risk of bone fractures 7
  • Fundic gland polyps 6, 7

Important Caveats

• Use the shortest duration of PPI therapy appropriate to the condition being treated 6, 7
• Long-term PPI therapy is not recommended unless ongoing NSAID use is necessary 2
• Avoid concomitant use of omeprazole with clopidogrel due to drug interaction 6
• Be aware of rebound acid hypersecretion when discontinuing prolonged PPI therapy, which can persist for up to 8 weeks 2

H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2%, making it a critical component of peptic ulcer management 2, 3.