What is the treatment therapy for Peptic Ulcer Disease (PUD)?

Treatment Therapy for Peptic Ulcer Disease (PUD)

Immediate Pharmacological Management

Start proton pump inhibitor (PPI) therapy immediately upon diagnosis, with standard dosing of omeprazole 20mg daily, lansoprazole 30mg daily, or pantoprazole 40mg daily for uncomplicated ulcers, achieving 80-100% healing rates within 4 weeks for duodenal ulcers and 8 weeks for gastric ulcers. 1, 2, 3

Standard PPI Regimens by Ulcer Type

• Duodenal ulcers: Treat with PPI for 4-6 weeks, achieving 95-98% healing rates 2, 4
• Gastric ulcers: Treat with PPI for 6-8 weeks (8 weeks if ulcer >2cm), achieving 94-96% healing rates 5, 1, 2, 3
• Uncomplicated ulcers: Omeprazole 20mg once daily healed 82% of duodenal ulcers at 4 weeks versus 63% with ranitidine 4

Management of Bleeding Peptic Ulcers

For bleeding peptic ulcers with high-risk stigmata, administer high-dose PPI therapy: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours, which significantly reduces rebleeding from 10.3% to 5.9%. 5, 1, 6

Bleeding Ulcer Protocol

• Pre-endoscopy: Start PPI therapy immediately and consider erythromycin to improve gastric visualization and reduce need for repeat endoscopy 5, 1
• During endoscopy: Perform endoscopic hemostasis as first-line treatment 5
• Post-endoscopy: Continue high-dose PPI infusion for 72 hours, then transition to standard oral PPI for 6-8 weeks 5, 1
• Critical caveat: PPIs should not replace urgent endoscopy in patients with active bleeding 5, 1

Recurrent Bleeding Management

• First-line: Repeat endoscopy immediately 5
• Alternative: Transcatheter angioembolization if patient is hemodynamically stable and resources available 5
• Risk context: 33% rebleeding risk within 1-2 years and 40-50% risk over 10 years without proper management 5

H. pylori Testing and Eradication

Test all patients with peptic ulcer disease for H. pylori infection, as eradication reduces ulcer recurrence from 50-60% to 0-2%. 5, 1, 2, 3

H. pylori Eradication Regimens

• First-line (low clarithromycin resistance): Standard triple therapy for 14 days - PPI standard dose twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily, achieving 69-83% eradication rates 1, 4
• Alternative first-line: Omeprazole 20mg twice daily + clarithromycin 500mg twice daily + amoxicillin 1g twice daily for 10 days achieved 77-90% eradication versus 33-43% with antibiotics alone 4
• High clarithromycin resistance: Sequential therapy for 10 days - Days 1-5: PPI twice daily + amoxicillin 1000mg twice daily; Days 6-10: PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily 1
• Second-line (if first-line fails): Levofloxacin 500mg once daily + amoxicillin 1000mg twice daily + PPI twice daily for 10 days 1
• Confirm eradication: Retest after treatment completion to ensure success 5, 1

NSAID-Associated Ulcer Management

Discontinue NSAID therapy immediately when possible, as this heals 95% of ulcers and reduces recurrence from 40% to 9%. 1, 2, 3

When NSAIDs Cannot Be Discontinued

• Switch to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 1
• Maintain long-term PPI therapy indefinitely for gastroprotection 5, 1, 2
• Eradicate H. pylori if present to further reduce risk 1
• Critical error to avoid: H2-receptor antagonists should NOT be used for NSAID-associated ulcers as they only reduce duodenal ulcer risk, not gastric ulcer risk 2

Long-Term Maintenance Therapy

Continue PPI therapy for 6-8 weeks after initial treatment to allow complete mucosal healing, then discontinue unless specific indications exist for long-term use. 5, 1

Indications for Long-Term PPI Therapy

• Chronic NSAID users who cannot discontinue 5, 1
• Recurrent ulcers despite H. pylori eradication 1
• NOT indicated for routine maintenance after healing in H. pylori-negative, non-NSAID users 5

Alternative Agents: What NOT to Use First-Line

• Potassium-competitive acid blockers (P-CABs) like vonoprazan should NOT be used as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 1, 2
• H2-receptor antagonists (ranitidine) are less effective than PPIs, with only 63% healing at 4 weeks versus 82% with omeprazole 2, 4, 7

Common Pitfalls to Avoid

• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 1
• Using PPIs to delay endoscopy in actively bleeding patients - endoscopy must not be delayed 5, 1
• Overlooking alarm symptoms (hematemesis, melena, significant weight loss, dysphagia) requiring prompt endoscopy 2
• Assuming all ulcers are acid-related without addressing H. pylori or NSAID causes 2
• Poor compliance with gastroprotective agents in high-risk patients 2