What is the typical prescription for a patient with a gastric ulcer?

Gastric Ulcer Prescription

For a patient with gastric ulcer, prescribe a proton pump inhibitor (PPI) such as omeprazole 40 mg once daily for 4-8 weeks, test for H. pylori infection, and if positive, initiate eradication therapy with triple therapy (PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days). 1, 2

Initial Treatment Approach

Acid Suppression Therapy

• Start omeprazole 40 mg once daily for 4-8 weeks as first-line therapy for gastric ulcer healing 2, 3
• Alternative PPIs include lansoprazole 30 mg daily, pantoprazole 40 mg daily, or rabeprazole 20 mg daily for 2-4 weeks, though gastric ulcers typically require the longer 4-8 week duration 3
• Omeprazole 40 mg once daily achieves 82.7% healing at 8 weeks compared to 48.1% with placebo 2
• Take PPIs before meals for optimal efficacy 2

H. pylori Testing and Eradication

• Test all gastric ulcer patients for H. pylori infection using urea breath test (88-95% sensitivity), stool antigen testing (94% sensitivity), or endoscopic biopsy 1
• If H. pylori positive, prescribe standard triple therapy: 1, 4, 2
  • PPI (omeprazole 20 mg) twice daily
  • Amoxicillin 1000 mg twice daily
  • Clarithromycin 500 mg twice daily
  • Duration: 14 days total
• For patients with an ulcer present at therapy initiation, continue omeprazole 20 mg once daily for an additional 18 days after completing triple therapy for complete ulcer healing 2
• Start eradication therapy 72-96 hours after beginning intravenous PPI administration in bleeding ulcer cases 1

Alternative Eradication Regimens

• If clarithromycin resistance is high or first-line therapy fails: use 10-day sequential therapy with amoxicillin, clarithromycin, metronidazole, and PPI 1
• Second-line therapy if eradication fails: levofloxacin 500 mg once daily + amoxicillin 1000 mg twice daily + PPI twice daily for 10 days 1

NSAID-Related Gastric Ulcers

Management Strategy

• Discontinue NSAIDs immediately if possible as they are a primary cause of gastric ulcers 1, 5
• If NSAIDs must be continued, prescribe omeprazole 20 mg once daily for healing (83% healing rate at 8 weeks) 6, 7
• For NSAID-induced ulcers requiring continued NSAID therapy, omeprazole 20 mg once daily is superior to misoprostol 200 mcg four times daily in both efficacy and tolerability 7

Prevention in High-Risk Patients

• For patients requiring long-term NSAIDs with prior ulcer history: prescribe PPI co-therapy as standard doses of PPIs significantly reduce gastric and duodenal ulcers 1
• Misoprostol 200 mcg four times daily can prevent NSAID-related ulcers but causes diarrhea and abdominal pain in many patients, limiting its use 1
• H2-receptor antagonists reduce duodenal ulcers but NOT gastric ulcers, making them inadequate for gastric ulcer prevention 1

Potassium-Competitive Acid Blockers (P-CABs)

• Do not use P-CABs (vonoprazan, tegoprazan) as first-line therapy for gastric ulcer treatment due to higher costs and more limited availability 1
• Vonoprazan 20 mg once daily is noninferior to lansoprazole 30 mg for gastric ulcer healing (94% vs 94% at 8 weeks) but should be reserved for PPI treatment failures 1
• P-CABs may be useful when PPIs fail, assuming ulcers are not secondary to cancer, opportunistic infections, vasculitis, or ischemia 1

Endoscopic Evaluation and Biopsy

• All gastric ulcers require endoscopy with biopsy and histological examination to exclude malignancy, as we cannot reliably determine which gastric ulcers are benign 5
• Repeat endoscopy is necessary if the ulcer does not heal after 8 weeks of treatment 2

Common Pitfalls and Caveats

• Poor compliance with gastroprotective agents increases the risk of NSAID-induced upper GI adverse events 4-6 times 1
• Avoid combining multiple NSAIDs (including low-dose aspirin), antiplatelet drugs, anticoagulants, or steroids as this significantly increases ulcer risk 1
• H. pylori eradication alone is insufficient for patients with previous ulcer history who need NSAIDs—additional PPI therapy is mandatory 1
• Long-term PPI use may be associated with increased risks of pneumonia and hip fracture, though this requires confirmation 1
• Successful H. pylori eradication significantly reduces gastric ulcer recurrence rates (6% vs 60% at 6 months in eradicated vs non-eradicated patients) 2
• Ulcer etiology affects treatment success—H. pylori-associated ulcers heal better than idiopathic or NSAID-related ulcers with P-CAB therapy 1