What medications are used to treat epigastric pain?

Medications for Epigastric Pain

Proton pump inhibitors (PPIs) are the first-line medication for epigastric pain, with omeprazole 20 mg once daily before meals being the standard initial dose, as this symptom pattern typically indicates acid-related disease that responds well to acid suppression. 1, 2

First-Line Treatment: PPIs

• Start omeprazole 20 mg once daily taken before breakfast for patients with epigastric pain (ulcer-like dyspepsia), as this dose heals most duodenal ulcers within 4 weeks and gastric ulcers within 4-8 weeks 3

• If symptoms persist after 4 weeks on omeprazole 20 mg daily, increase to 40 mg once daily rather than switching to IV formulation, as higher oral doses are more effective for refractory symptoms 2, 3

• Alternative PPIs include lansoprazole 30 mg daily, pantoprazole 40 mg daily, or rabeprazole 20 mg daily, though omeprazole has the most extensive evidence base for epigastric pain 4, 5

• Continue treatment for 4-8 weeks depending on symptom severity, with most patients healing within this timeframe 3

Critical Diagnostic Considerations Before Treatment

• Rule out cardiac causes first - obtain ECG and troponins, as myocardial infarction can present with epigastric pain as the primary symptom 6

• Test for Helicobacter pylori in patients with persistent symptoms, as eradication reduces duodenal ulcer recurrence risk 1, 2, 3

• Refer for urgent endoscopy if patient is ≥55 years with alarm features (weight loss >9 kg, progressive symptoms despite PPI therapy, or treatment resistance) to exclude gastric malignancy 6

• Immediate imaging is mandatory if sudden severe epigastric pain with fever and abdominal rigidity occurs, as perforation carries 30% mortality if treatment is delayed 6

Second-Line Medications for Persistent Pain

If epigastric pain persists despite adequate PPI therapy:

• Tricyclic antidepressants (TCAs) are the most effective second-line option for abdominal pain, starting with amitriptyline 10 mg once daily at bedtime and titrating slowly to 30-50 mg daily 1

• TCAs ranked first in network meta-analyses for relief of abdominal pain in functional dyspepsia and IBS, performing better than all other drug classes 1

• Antispasmodics ranked second for abdominal pain relief and can be used if TCAs are not tolerated, though dry mouth, visual disturbance, and dizziness are common side effects 1

• Peppermint oil ranked third for pain relief and represents a well-tolerated alternative with fewer side effects than antispasmodics 1

Alternative Approaches for Specific Symptom Patterns

• If fullness, bloating, or satiety predominate rather than pain, consider adding a prokinetic agent instead of increasing PPI dose 1

• For patients with dysmotility-like symptoms, prokinetics may be more appropriate than acid suppression alone 1

Medications to Avoid

• Never use opioid analgesics for chronic epigastric pain in functional disorders, as they are ineffective and carry significant risks 1

• Avoid NSAIDs as they can worsen ulcer disease; if NSAID use is necessary, continue PPI therapy for gastroprotection 7

When IV Pantoprazole is Appropriate

• Reserve IV PPIs only for patients who cannot take oral medications due to severe vomiting or for prevention of rebleeding after endoscopic treatment of bleeding ulcers 2

• IV formulation offers no advantage over adequate oral dosing for uncomplicated epigastric pain 2

Helicobacter pylori Eradication Regimens

If H. pylori testing is positive:

• Triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days, then continue omeprazole 20 mg daily for additional 18 days if ulcer present 3

• Dual therapy: omeprazole 40 mg daily + clarithromycin 500 mg three times daily for 14 days, then continue omeprazole 20 mg daily for additional 14 days if ulcer present 3

• Triple therapy is preferred as dual therapy has higher rates of clarithromycin resistance development 3

Dosing Adjustments and Special Considerations

• Take all PPIs before meals for optimal absorption and efficacy 3

• Antacids may be used concomitantly with PPIs without reducing effectiveness 3

• For patients unable to swallow capsules, omeprazole can be opened and mixed with applesauce, but pellets must not be chewed or crushed 3

• Explain to patients that TCAs are used as "gut-brain neuromodulators" at low doses for pain, not as antidepressants, to improve adherence and reduce stigma 1