What is the recommended medication for treating stomach ulcers and Gastroesophageal Reflux Disease (GERD)?

Medication Recommendations for Stomach Ulcers and GERD

Proton pump inhibitors (PPIs) are the first-line pharmacological treatment for both stomach ulcers and GERD, with standard dosing of omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg once daily taken 30-60 minutes before meals. 1, 2, 3, 4

Initial Treatment Approach

For GERD

• Start with a standard-dose PPI once daily for 4-8 weeks as empiric therapy without requiring endoscopy for typical symptoms 2, 3
• Specific dosing options include: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, or esomeprazole 20 mg once daily 2
• Take PPIs 30-60 minutes before meals (typically before breakfast) for optimal acid suppression, as the medication needs to be present when proton pumps are actively secreting acid 2, 5, 4
• For patients with erosive esophagitis (LA grade C/D) who fail standard PPI therapy, consider switching to potassium-competitive acid blockers (P-CABs) like vonoprazan, though these should not be used as first-line therapy due to higher costs and less long-term safety data 1, 3

For Stomach (Gastric) Ulcers

• Lansoprazole 30 mg once daily for up to 8 weeks is the FDA-approved regimen for healing gastric ulcers 4
• Alternative equivalent dosing: omeprazole 20-40 mg, pantoprazole 40 mg, or rabeprazole 20 mg daily for 4-8 weeks 6, 7
• Gastric ulcers require longer treatment duration (4-8 weeks) compared to duodenal ulcers (4 weeks) 4, 7

For Duodenal Ulcers

• Lansoprazole 15 mg once daily for 4 weeks for short-term treatment, with 15 mg daily for maintenance of healed ulcers 4

Treatment Escalation Strategy

If Symptoms Persist After 4-8 Weeks

• Increase to twice-daily PPI dosing (e.g., omeprazole 20 mg twice daily or lansoprazole 30 mg twice daily) 2, 3
• This escalation is supported by expert consensus despite limited FDA approval for twice-daily regimens in most indications 2
• Consider endoscopy after failed empiric therapy to assess for complications, Barrett's esophagus, or alternative diagnoses 3

For Severe or Refractory Cases

• Higher-dose regimens may be needed: omeprazole 40 mg, lansoprazole 60 mg, or pantoprazole 80 mg daily for severe reflux with ulceration or stricture formation 7
• For extraesophageal GERD symptoms (chronic cough, laryngitis), use twice-daily PPI dosing for 8-12 weeks minimum, though response rates are lower than for typical GERD 3

Critical Considerations for Helicobacter pylori

• All patients with peptic ulcer disease should be tested for H. pylori and receive eradication therapy if positive 1
• Triple therapy regimen: PPI (lansoprazole 30 mg twice daily) + amoxicillin + clarithromycin for 10-14 days achieves >90% eradication rates 4, 7
• H. pylori eradication eliminates the risk of peptic ulcer mortality and significantly reduces ulcer recurrence 1
• Important caveat: Many patients will have residual dyspeptic symptoms even after successful H. pylori eradication, requiring continued acid suppression 1

Maintenance Therapy

• After initial symptom control, attempt to titrate to the lowest effective PPI dose (typically 15-20 mg daily of omeprazole/lansoprazole equivalents) 3, 6
• For erosive esophagitis, maintenance therapy with lansoprazole 15 mg daily prevents relapse, though studies have not extended beyond 12 months 4
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks, though long-term PPI use appears safe based on available data 3, 8
• After discontinuation, nearly all patients with esophagitis will relapse within 30 weeks, so the regimen that induced remission should be continued for maintenance 8

Alternative and Adjunctive Therapies

H2-Receptor Antagonists

• H2RAs like famotidine are second-line options when PPIs are not available or tolerated, but they are significantly less effective for healing erosive esophagitis 1, 2
• H2RAs should not be used as monotherapy for moderate-to-severe GERD 2

Antacids

• Can provide immediate symptom relief while waiting for PPI onset of action 2
• Alginate-containing antacids are particularly effective for breakthrough symptoms 2
• May be used concomitantly with PPIs 4

Prokinetic Agents

• May be considered for patients with dysmotility-like symptoms (fullness, bloating, early satiety) 1
• Avoid metoclopramide due to limited efficacy and potential neurologic side effects 2, 3
• Acotiamide, itopride, and mosapride show some efficacy but are mostly unavailable outside Asia 1

Common Pitfalls to Avoid

• Do not take PPIs with sucralfate: Administer lansoprazole at least 30 minutes prior to sucralfate to avoid reduced PPI absorption 5, 4
• Do not crush or chew PPI capsules: The enteric coating protects the acid-labile medication; swallow whole or open capsules and mix contents with appropriate foods/liquids per FDA instructions 4
• Do not use P-CABs as first-line therapy for uninvestigated heartburn or non-erosive GERD due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 1, 3
• Do not assume all PPIs have different efficacies: At equipotent doses (omeprazole 20-40 mg, lansoprazole 30 mg, pantoprazole 40 mg, rabeprazole 20 mg), all PPIs show similar healing rates and symptom control 6, 7, 9

Special Populations

NSAID-Associated Ulcers

• Lansoprazole 30 mg once daily for 8 weeks for healing NSAID-associated gastric ulcers 4
• For risk reduction in patients continuing NSAIDs: lansoprazole 15 mg once daily for up to 12 weeks 4
• P-CABs (vonoprazan 10-20 mg) are noninferior to PPIs for secondary peptic ulcer prophylaxis in patients requiring long-term NSAIDs or aspirin, but are not recommended as first-line prophylactic therapy 1

Pediatric Patients (1-17 years)

• For children ≤30 kg: lansoprazole 15 mg once daily for up to 12 weeks 4
• For children >30 kg: lansoprazole 30 mg once daily for up to 12 weeks 4
• Do not exceed recommended duration in pediatric patients, as safety beyond 12 weeks has not been established 4

Hepatic Impairment

• Reduce dose to lansoprazole 15 mg daily in patients with severe liver impairment (Child-Pugh C) 4

Long-Term Safety Considerations

• PPIs may cause hypergastrinemia, but no cases of gastric cancer or endocrine neoplasia associated with PPI treatment have been documented 8
• Potential risks include acute tubulointerstitial nephritis, Clostridium difficile infection, bone fractures with long-term use, and certain types of lupus erythematosus 4
• P-CABs raise serum gastrin levels higher than PPIs, with levels returning toward baseline within weeks after discontinuation 1
• Any safety concerns related to acid inhibition with PPIs would be expected to be shared by P-CABs, and more potent acid inhibition with P-CABs may theoretically increase adverse effects, though this remains unknown 1