What medications are used to treat ulcers?

Medications for Ulcer Treatment

Initiate proton pump inhibitor (PPI) therapy immediately upon diagnosis of peptic ulcer disease with standard doses: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg once daily for 6-8 weeks to achieve complete mucosal healing. 1

First-Line Pharmacological Management

Standard Ulcer Treatment

• Start PPI therapy as soon as ulceration is diagnosed, using standard doses taken before meals for 6-8 weeks 1, 2, 3
• Standard PPI doses are:
  • Omeprazole 20mg once daily 1, 3
  • Lansoprazole 30mg once daily 1
  • Pantoprazole 40mg once daily 1
• For gastric ulcers specifically, use the same standard PPI doses but extend treatment duration to 4-8 weeks (longer than duodenal ulcers) 1, 4
• Antacids may be used concomitantly with PPIs 3

Bleeding Ulcers Require Intensive Therapy

• For actively bleeding ulcers, administer high-dose PPI therapy: 80mg bolus followed by 8mg/hour continuous infusion for 72 hours, then transition to standard oral PPI therapy 1, 2
• Pre-endoscopy erythromycin improves visualization and reduces need for repeat procedures 1, 2
• PPIs should not replace urgent endoscopy in patients with active bleeding (hematemesis, melena, hemodynamic instability) 1, 2
• Most patients who undergo endoscopic hemostasis should be hospitalized for at least 72 hours, as 60-76% of rebleeding episodes occur within this timeframe 2

Helicobacter pylori Eradication—Critical for Preventing Recurrence

Testing and Importance

• Test all gastric ulcer patients for H. pylori infection—failure to eradicate leads to 40-50% recurrence rates over 10 years 1, 2, 5
• Never skip H. pylori testing—this single omission accounts for the majority of treatment failures and recurrences 1
• Confirm eradication after completing treatment to prevent recurrence 1, 2

First-Line Eradication Regimens

For areas with low clarithromycin resistance:

• Standard triple therapy for 14 days: 1, 2, 5, 3
  • PPI standard dose twice daily (omeprazole 20mg twice daily)
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1000mg twice daily (or metronidazole 500mg twice daily if penicillin-allergic)
• In patients with active ulcer at therapy initiation, continue omeprazole 20mg once daily for an additional 18 days for ulcer healing 3

For areas with high clarithromycin resistance:

• Sequential therapy for 10 days: 1, 2, 5
  • Days 1-5: PPI twice daily + amoxicillin 1000mg twice daily
  • Days 6-10: PPI twice daily + clarithromycin 500mg twice daily + metronidazole 500mg twice daily

Second-Line Therapy if First-Line Fails

• 10-day levofloxacin-amoxicillin triple therapy: 2, 5
  • PPI standard dose twice daily
  • Levofloxacin 500mg once daily (or 250mg twice daily)
  • Amoxicillin 1000mg twice daily

Alternative Dual Therapy (Less Preferred)

• Omeprazole 40mg once daily + clarithromycin 500mg three times daily for 14 days 3
• In patients with active ulcer, add an additional 14 days of omeprazole 20mg once daily for ulcer healing 3

NSAID-Associated Ulcers

Management Strategy

• Discontinue NSAID therapy whenever clinically feasible—this is the most effective intervention, healing 95% of ulcers and reducing recurrence from 40% to 9% 1, 2
• If NSAIDs must be continued, maintain PPI therapy long-term to prevent recurrence 1, 2
• Consider switching to selective COX-2 inhibitor (celecoxib) with lower gastric toxicity 2
• Omeprazole 20mg once daily is the optimal dose for healing NSAID-associated ulcers based on efficacy and tolerability 6

Long-Term Maintenance Therapy

• Continue PPI therapy long-term only in specific populations: 2
  • Chronic NSAID users who cannot discontinue
  • Patients with recurrent ulcers despite H. pylori eradication
• For maintenance of healed erosive esophagitis, use omeprazole 20mg once daily (controlled studies do not extend beyond 12 months) 3

Critical Pitfalls to Avoid

• Never use H2-receptor antagonists (ranitidine, cimetidine) as first-line therapy—standard doses are ineffective for gastric ulcers, and even double doses show limited benefit 1
• Do not use potassium-competitive acid blockers (P-CABs) like vonoprazan as first-line therapy due to higher costs, limited availability, and less robust long-term safety data compared to PPIs 2
• PPIs may reduce absorption of medications requiring acidic environments (ketoconazole, iron, certain antiretrovirals) 1
• If a patient does not respond to 8 weeks of PPI treatment, an additional 4 weeks may be given 3