What is the recommended treatment for ulcers?

Recommended Treatment for Ulcers

Start proton pump inhibitor (PPI) therapy immediately at standard dose (omeprazole 20-40mg once daily) for 6-8 weeks, test all patients for H. pylori and provide eradication therapy if positive, and discontinue NSAIDs when possible. 1, 2

Immediate Pharmacological Management

Standard (Non-Bleeding) Ulcers

• Initiate PPI therapy as soon as ulcer is diagnosed with omeprazole 20mg once daily for duodenal ulcers (4 weeks minimum) or 40mg once daily for gastric ulcers (4-8 weeks), taken before meals 1, 3, 4
• Most duodenal ulcers heal within 4 weeks, but some require an additional 4 weeks; gastric ulcers larger than 2cm may require the full 8 weeks 3, 4
• Healing rates with PPI therapy reach 80-100% for uncomplicated ulcers 4

Bleeding Ulcers (High-Risk)

• Administer high-dose PPI immediately: 80mg omeprazole IV bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy 5, 1
• This high-dose regimen significantly reduces rebleeding (5.9% vs 10.3%), need for endoscopic retreatment, and mortality compared to placebo 5
• Give pre-endoscopy erythromycin to improve visualization and reduce need for repeat endoscopy 1
• Do not delay endoscopy - PPIs should not replace urgent endoscopy in active bleeding 1

H. pylori Testing and Eradication

Universal Testing Requirement

• Test all patients with peptic ulcers for H. pylori infection - failure to test leads to recurrence rates of 40-50% over 10 years 1, 4
• H. pylori is present in approximately 42% of peptic ulcer patients and eradication reduces recurrence from 50-60% to 0-2% 4

First-Line Eradication Therapy (Low Clarithromycin Resistance Areas <20%)

• Standard triple therapy for 14 days: PPI standard dose twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily 1, 2
• This achieves eradication rates of 77-90% 2
• For patients with active ulcer at therapy initiation, continue omeprazole 20mg once daily for additional 18 days for ulcer healing 3

Alternative First-Line (High Clarithromycin Resistance >20%)

• Bismuth-based quadruple therapy for 14 days when triple therapy has failed or in high-resistance areas 2

Second-Line Therapy (If First-Line Fails)

• Levofloxacin-amoxicillin triple therapy for 10-14 days: PPI standard dose twice daily + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily 1, 2
• Switch to this regimen without waiting for culture results 2

Timing and Confirmation

• Start H. pylori eradication immediately when oral feeding begins after bleeding ulcer, not at discharge - delaying reduces compliance and increases loss to follow-up 2
• Confirm eradication at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI using urea breath test (88-95% sensitivity) or stool antigen test (94% sensitivity) 2
• Eradication confirmation is mandatory for gastric ulcers 2

NSAID-Associated Ulcer Management

Discontinuation Strategy

• Discontinue NSAID therapy whenever possible - this heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 4
• When discontinuation is not feasible, consider changing to a less ulcerogenic NSAID (e.g., from ketorolac to ibuprofen) 4

Continued NSAID Use

• Maintain long-term PPI therapy if NSAID must continue - this is the only scenario requiring indefinite PPI use 1
• Omeprazole 20mg once daily heals significantly more NSAID-associated ulcers (83% gastric, 93% duodenal at 8 weeks) compared to ranitidine or misoprostol 6
• Test for and eradicate H. pylori even in NSAID users, as this provides additional protection 4

Duration of PPI Therapy

Standard Duration

• 6-8 weeks of PPI therapy for initial ulcer healing, then discontinue in uncomplicated cases 1
• Prolonged PPI beyond this period is not recommended for uncomplicated duodenal ulcers after successful H. pylori eradication (>90% healing rate without additional acid suppression) 2

Extended Therapy Indications

• Continue PPI until complete healing confirmed for gastric ulcers and complicated duodenal ulcers 2
• Long-term PPI only for: chronic NSAID users who cannot discontinue, and patients with recurrent ulcers despite H. pylori eradication 1

Common Pitfalls to Avoid

• Never delay H. pylori treatment until after hospital discharge - this significantly reduces compliance 2
• Do not continue long-term PPI for uncomplicated duodenal ulcers after successful H. pylori eradication - this is unnecessary and increases costs 2
• Do not rely on PPIs alone to replace urgent endoscopy in patients with active bleeding 1
• Remember that PPIs may reduce absorption of medications requiring acidic environment 1
• Always confirm H. pylori eradication - do not assume treatment success 2

Special Populations

Refractory Ulcers

• For ulcers resistant to standard H2-receptor antagonist therapy, omeprazole 40mg once daily achieves 97% healing rates within 4-8 weeks 7

Pediatric Patients (2-16 years)

• Weight-based dosing: 10mg once daily for patients 10-20kg, 20mg once daily for patients ≥20kg, for 4-8 weeks 3