What is the recommended management for Peptic Ulcer Disease (PUD)?

Management of Peptic Ulcer Disease

For uncomplicated peptic ulcer disease, initiate standard-dose PPI therapy (omeprazole 20-40mg or lansoprazole 30mg once daily) for 6-8 weeks, test all patients for H. pylori and eradicate if present, and discontinue NSAIDs whenever possible. 1

Initial Pharmacological Treatment

Standard PPI Therapy

• Start PPI therapy as soon as possible after diagnosis with a typical dose of 20-40mg once daily for 6-8 weeks to allow complete mucosal healing 1
• PPIs heal peptic ulcers in approximately 80-100% of patients within 4 weeks, though gastric ulcers larger than 2cm may require 8 weeks of treatment 2
• After the initial healing period, discharge patients with a prescription for single daily-dose oral PPI for a duration dictated by the underlying etiology 3

Bleeding Peptic Ulcers

• For bleeding ulcers with high-risk stigmata after endoscopic hemostasis, administer an 80mg PPI bolus followed by 8mg/hour continuous infusion for 72 hours 1, 4
• Following the 72-hour high-dose infusion, transition to standard oral PPI therapy for 6-8 weeks 1
• Most patients who undergo endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 3
• PPI therapy should not replace urgent endoscopy in patients with active bleeding 1

H. pylori Testing and Eradication

Universal Testing

• Test all patients with peptic ulcers for H. pylori infection and confirm eradication after treatment completion 1, 4
• Failure to test for H. pylori leads to recurrence rates of 40-50% over 10 years 1
• Eradication of H. pylori decreases peptic ulcer recurrence rates from approximately 50-60% to 0-2% 2

First-Line Eradication Regimen

• For patients with low clarithromycin resistance, use standard triple therapy for 14 days: PPI standard dose twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily (or metronidazole 500mg twice daily if penicillin allergic) 1

Alternative Regimens

• For high clarithromycin resistance areas, use sequential therapy for 10 days: days 1-5 with PPI twice daily + amoxicillin 1000mg twice daily, then days 6-10 with PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily 1
• If first-line therapy fails, use 10-day levofloxacin-amoxicillin triple therapy: PPI twice daily + levofloxacin 500mg once daily + amoxicillin 1000mg twice daily 1

NSAID-Associated Ulcers

NSAID Discontinuation

• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 1, 2
• When NSAIDs cannot be discontinued, switch to a selective COX-2 inhibitor (celecoxib) with lower gastric toxicity and maintain long-term PPI therapy 1

Continued NSAID Use

• If NSAID therapy must continue, maintain PPI therapy long-term for secondary prophylaxis 3, 1
• For patients requiring continuous NSAID therapy, PPIs heal a significantly higher percentage of peptic ulcers in 8 weeks compared to H2-receptor antagonists 5

Long-Term Management

Duration of PPI Therapy

• Continue PPI therapy long-term only in specific populations: chronic NSAID users who cannot discontinue, patients with recurrent ulcers despite H. pylori eradication, and those with complicated ulcers 1
• Use the shortest duration of PPI therapy appropriate to the condition being treated to minimize risks of long-term complications 6, 7

H. pylori-Negative Ulcers

• H. pylori-negative ulcers are more aggressive, with high recurrence rates and increased risk of bleeding and perforation 5
• Long-term PPI therapy may be necessary for these patients 5

Important Safety Considerations

PPI-Related Risks

• Long-term PPI use (>3 years) may lead to vitamin B12 malabsorption, hypomagnesemia, increased risk of C. difficile infection, osteoporosis-related fractures, and fundic gland polyps 6, 7
• Monitor magnesium levels in patients expected to be on prolonged treatment or taking medications like digoxin or diuretics 6, 7
• PPIs may cause cutaneous and systemic lupus erythematosus; discontinue if signs or symptoms develop 6, 7

Drug Interactions

• Avoid concomitant use of omeprazole with clopidogrel, as it reduces clopidogrel's antiplatelet activity even when administered 12 hours apart 7
• Temporarily stop PPI treatment at least 14 days before assessing chromogranin A levels to avoid false positive results for neuroendocrine tumors 6, 7

Alternative Therapies

• 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, 8
• P-CABs may be useful in PPI treatment failures, assuming ulcers are not secondary to processes that cause ulcers without acid 8

Common Pitfalls

• Do not use PPI therapy as a substitute for urgent endoscopy in actively bleeding patients 1
• Always confirm H. pylori eradication after treatment, as failure to do so is a major cause of ulcer recurrence 1, 4
• Avoid unnecessarily prolonged PPI therapy beyond what is medically indicated to minimize long-term adverse effects 6, 7