What is the treatment for a duodenal ulcer?

Treatment for Duodenal Ulcer

The first-line treatment for duodenal ulcer includes a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily for 4 weeks, along with testing and eradication therapy for H. pylori if present. 1, 2

Initial Treatment Approach

• PPIs are the preferred agents for therapy of duodenal ulcers, with omeprazole showing superior healing rates (75% at 4 weeks) compared to placebo (27%) and ranitidine (63%) 1
• Standard PPI treatment duration for duodenal ulcer is 4 weeks 3, 1
• Lansoprazole is also FDA-approved for short-term treatment (4 weeks) for healing and symptom relief of active duodenal ulcer 3
• H2-receptor antagonists like ranitidine are less effective than PPIs but can be used as an alternative, with healing rates of approximately 73% at 4 weeks 4

H. pylori Eradication

• Testing for H. pylori infection should be performed in all patients with duodenal ulcer 2, 5
• In H. pylori-positive patients, eradication therapy is strongly recommended to prevent recurrent bleeding and ulcer recurrence 5
• Triple therapy regimens are recommended as first-line treatment for H. pylori 5, 1:
  • Standard triple therapy: PPI + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 5, 1
  • Sequential therapy may be considered in areas with high clarithromycin resistance 5
• Dual therapy (PPI + amoxicillin) can be used as an alternative when clarithromycin is contraindicated or resistance is suspected 3, 1

Treatment Based on Etiology

• For NSAID-induced duodenal ulcers:
  • Discontinue NSAIDs if possible 5, 2
  • If NSAIDs must be continued, add a PPI for gastroprotection 5
  • Consider using the lowest effective NSAID dose for the shortest duration 5
• For H. pylori-associated ulcers:
  • Eradication therapy should be started after 72-96 hours of intravenous PPI administration in cases of bleeding ulcers 5
  • Second-line therapy with 10-day levofloxacin-amoxicillin triple therapy is recommended if first-line therapy fails 5

Prevention of Recurrence

• After initial healing, maintenance therapy with a PPI may be necessary for patients at high risk of recurrence 3, 1
• Lansoprazole is indicated for maintenance of healed duodenal ulcers, though controlled studies do not extend beyond 12 months 3
• Avoid all NSAIDs as they significantly increase the risk of ulcer recurrence and complications 2, 5
• H. pylori eradication has been shown to reduce the risk of duodenal ulcer recurrence 3, 1

Common Pitfalls and Caveats

• H2-receptor antagonists decrease the risk of NSAID-associated duodenal ulcers but not gastric ulcers, making them less effective overall than PPIs 5
• Misoprostol can be effective for preventing NSAID-related ulcers but has significant side effects (diarrhea, abdominal pain) that limit its use 5
• Long-term PPI use may be associated with increased risks of certain adverse events such as pneumonia and hip fracture, requiring risk-benefit assessment for maintenance therapy 5, 2
• Poor compliance with gastroprotective agents can increase the risk of NSAID-induced upper GI adverse events by 4-6 times 5