What can be given for severe peptic ulcer disease (PUD) pain?

From the Guidelines

For severe peptic ulcer disease (PUD) pain, proton pump inhibitors (PPIs) like omeprazole (20-40mg once daily) or pantoprazole (40mg once daily) are the first-line treatment, providing rapid relief by reducing stomach acid production. These can be combined with antacids (such as aluminum/magnesium hydroxide preparations) for immediate symptom relief. H2 receptor antagonists like famotidine (20mg twice daily) may be used as alternatives. For breakthrough pain, acetaminophen (up to 1000mg every 6 hours) is preferred over NSAIDs, which can worsen ulcers. If Helicobacter pylori infection is present, triple therapy consisting of a PPI plus two antibiotics (typically amoxicillin 1g twice daily and clarithromycin 500mg twice daily) for 7-14 days is essential for healing, as recommended by guidelines 1.

Key Considerations

• PPIs are the preferred first-line treatment for severe PUD pain due to their ability to rapidly reduce stomach acid production.
• Antacids and H2 receptor antagonists can be used as adjunctive therapies for symptom relief.
• Acetaminophen is the preferred analgesic for breakthrough pain due to its lower risk of exacerbating ulcers compared to NSAIDs.
• Eradication of H. pylori infection is crucial in patients with PUD, and triple therapy with a PPI and two antibiotics is the recommended treatment regimen 1.
• Patients should avoid alcohol, smoking, spicy foods, and caffeine during treatment, as these can exacerbate symptoms.

Management of Complications

• Prompt medical attention is necessary if pain is accompanied by vomiting blood, black stools, or severe, sudden abdominal pain, as these may indicate complications requiring emergency intervention, such as perforation or bleeding 1.
• In patients with bleeding peptic ulcer and positive tests for HP infection, eradication therapy is recommended to avoid recurrent bleeding, with standard triple therapy being the first-line treatment option 1.

Recent Evidence

• A recent study published in 2024 found that potassium-competitive acid blockers (P-CABs) may be useful in PPI treatment failures of ulcers, but are not recommended as first-line therapy due to their higher costs and limited availability 1.
• The use of P-CABs for secondary ulcer prophylaxis in patients at risk for ulcer recurrence has shown promise, with vonoprazan demonstrating noninferiority to lansoprazole in preventing ulcer recurrence 1.

Overall, the management of severe PUD pain requires a multifaceted approach that includes pharmacological therapy, lifestyle modifications, and prompt recognition of complications. By following these guidelines and considering the latest evidence, healthcare providers can optimize treatment outcomes and improve patient quality of life.

From the FDA Drug Label

2.1 Recommended Adult Dosage Regimen by Indication Table 1 shows the recommended dosage of omeprazole in adult patients by indication Indication Dosage of Omeprazole Treatment of Active Duodenal Ulcer 20 mg once daily 4 weeks Active Benign Gastric Ulcer 40 mg once daily 4 to 8 weeks

For severe peptic ulcer disease (PUD) pain, omeprazole can be given at a dosage of 40 mg once daily for 4 to 8 weeks for active benign gastric ulcers, and 20 mg once daily for 4 weeks for active duodenal ulcers 2.

From the Research

Treatment for Severe Peptic Ulcer Disease (PUD) Pain

• Proton pump inhibitors (PPI) are the most effective way to treat severe PUD pain, and should be administered in the morning on an empty stomach in a single daily dose 3
• PPIs play an essential role in the eradication treatment of Helicobacter pylori infection, which is a common cause of PUD 3, 4
• For patients with massive bleeding from the peptic ulcer, endoscopic hemostasis and parenteral administration of PPI for at least 72 hours are used in therapy 3
• In patients with Helicobacter pyli infection, triple therapy with a PPI plus two antibiotics can be effective in healing gastric ulcers, especially for smaller ulcers (< 1.0 cm in diameter) 5
• Omeprazole, a type of PPI, has been shown to be effective in healing NSAID-induced peptic ulcers and erosions, and in preventing relapse 4, 6
• The use of PPIs, such as omeprazole, can also help to reduce the risk of ulcer relapse in patients who have undergone eradication treatment for H. pyli infection 7