What is the first-line treatment for an adult patient with a stomach ulcer, considering various medications such as proton pump inhibitors (PPIs) like pantoprazole (Pantocid), rabeprazole (Rabicip), and omeprazole (Omez)?

First-Line Treatment for Uncomplicated Gastric Ulcer in Adults

For uncomplicated gastric ulcers in adults, prescribe a standard-dose proton pump inhibitor (PPI) once daily for 4-8 weeks: pantoprazole 40 mg, omeprazole 20 mg, rabeprazole 20 mg, or lansoprazole 30 mg, taken 30-60 minutes before the first meal of the day. 1, 2, 3

Specific PPI Selection and Dosing

Standard Uncomplicated Gastric Ulcer

• Pantoprazole 40 mg once daily for 4-8 weeks, taken 30 minutes before food 3, 4
• Omeprazole 20 mg once daily for 4-8 weeks, taken before meals 2
• Rabeprazole 20 mg once daily for 4-8 weeks, taken 30 minutes before food 1, 5
• Lansoprazole 30 mg once daily for 4-8 weeks, taken 30 minutes before food 5, 6

All four PPIs demonstrate equivalent efficacy at these standard doses for uncomplicated gastric ulcers. 5, 7, 6 The choice between them should be based on drug interactions and patient-specific factors rather than efficacy differences. 7, 6

H. pylori-Positive Gastric Ulcer (Triple Therapy)

If H. pylori testing is positive, prescribe omeprazole 20 mg twice daily (or equivalent PPI) combined with clarithromycin 500 mg twice daily and amoxicillin 1000 mg twice daily for 10-14 days. 1, 2 After completing eradication therapy, continue the PPI at standard once-daily dosing for an additional 4-6 weeks to ensure complete ulcer healing. 1

Bleeding Gastric Ulcer (High-Risk)

For bleeding ulcers with high-risk stigmata after endoscopic hemostasis, use high-dose IV PPI: 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours, then transition to pantoprazole 40 mg twice daily for days 4-14, followed by once-daily dosing. 8, 1 This regimen reduces rebleeding by 63% compared to once-daily dosing. 1

NSAID-Associated Ulcer

Discontinue all NSAIDs immediately when gastric ulcer is diagnosed, as this heals 95% of ulcers. 1 Prescribe pantoprazole 40 mg once daily (or equivalent PPI) for 4-8 weeks. 3, 4 If NSAID continuation is medically necessary, switch to celecoxib with continued PPI therapy. 1

Critical Drug Interaction Considerations

Avoid omeprazole and esomeprazole in patients taking clopidogrel, as they significantly inhibit CYP2C19 and reduce clopidogrel's antiplatelet activity, even when dosed 12 hours apart. 9 Pantoprazole is the preferred PPI for patients on clopidogrel due to minimal CYP2C19 inhibition. 9

Role of Adjunctive Medications

Antacids (Digene, Gelusil MPS, Rantac MPS, Mucaine, Tricaine MPS)

These provide symptomatic relief only and should not be used as monotherapy for gastric ulcers. 5 They may be used as needed for breakthrough symptoms while on PPI therapy, but must be taken 2 hours before or after the PPI to prevent drug interaction. 1 Antacids do not promote ulcer healing and are not part of guideline-based treatment. 5

Sucralfate

Sucralfate provides ulcer protection but is not recommended as first-line therapy in the PPI era. 5 It may be considered as adjunctive therapy in refractory cases, but PPIs remain superior for healing. 5

H2-Receptor Antagonists (Ranitidine)

Ranitidine is inferior to PPIs for gastric ulcer healing and should not be used as first-line therapy. 5, 7 PPIs heal ulcers faster and more completely than ranitidine 300 mg daily. 7 Note that ranitidine has been withdrawn from many markets due to contamination concerns.

Prokinetic Combinations (Pantop-D, Rabicip-D with domperidone; Pantop-IT with itopride; Pantop-L with levosulpiride)

These combinations are not indicated for uncomplicated gastric ulcers. 1 Prokinetics are reserved for gastroparesis or pre-endoscopy preparation in bleeding ulcers (erythromycin), not routine ulcer treatment. 8

Essential Testing and Follow-Up

Test all patients for H. pylori using urea breath test (88-95% sensitivity) or stool antigen test (94% sensitivity) before initiating therapy. 1 Serology is less reliable. 1 If H. pylori is positive, eradication therapy is mandatory, as failure to eradicate leads to 40-50% rebleeding risk over 10 years. 8, 1

Confirm H. pylori eradication 4-6 weeks after completing antibiotic therapy, as eradication reduces ulcer recurrence from 50-60% to 0-2%. 1

Common Pitfalls to Avoid

• Do not use antacids as monotherapy for gastric ulcers—they provide only symptomatic relief without promoting healing 5
• Do not prescribe omeprazole with clopidogrel—use pantoprazole instead 9
• Do not continue PPIs beyond 8 weeks without endoscopic re-evaluation if symptoms persist 9
• Do not forget to test for H. pylori—untreated infection leads to high recurrence rates 8, 1
• Do not use prokinetic combinations (domperidone, itopride, levosulpiride) for uncomplicated ulcers—they add no benefit and increase side effects 8, 1

Duration of Therapy

Continue PPI therapy for 6-8 weeks to allow complete mucosal healing. 8, 1 After healing, discontinue PPI unless the patient has ongoing NSAID use, recurrent ulcers despite H. pylori eradication, or other specific indications for long-term therapy. 8, 1