What is the recommended treatment regimen for an adult patient with a diagnosed gastric or duodenal ulcer using Rebamipide?

Rebamipide in Peptic Ulcer Disease

Rebamipide is not recommended as first-line therapy for gastric or duodenal ulcers; proton pump inhibitors (PPIs) remain the standard of care, with rebamipide reserved as adjunctive therapy in specific clinical scenarios, particularly for NSAID-induced ulcers or post-endoscopic procedure ulcers. 1, 2

First-Line Treatment: PPI Monotherapy

• Standard PPI therapy should be initiated immediately with omeprazole 20 mg daily, lansoprazole 30 mg daily, or pantoprazole 40 mg daily for 4-6 weeks for duodenal ulcers and 6-8 weeks for gastric ulcers 1, 2
• PPIs achieve 95-98% healing rates for duodenal ulcers and 94-96% healing rates for gastric ulcers, making them superior to all other agents 2
• H. pylori testing must be performed in all patients, with eradication therapy (standard triple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days) initiated if positive 3, 1

Role of Rebamipide: Adjunctive Therapy Only

When to Consider Rebamipide

Rebamipide 100 mg three times daily can be added to PPI therapy in these specific situations:

• NSAID-induced gastric ulcers where NSAIDs cannot be discontinued, as rebamipide significantly improves gastric inflammation scores and promotes ulcer healing in this population 4
• Post-endoscopic submucosal dissection (ESD) ulcers, where combination therapy (rebamipide + PPI) achieves higher scarring stage 1 rates (odds ratio 2.61,95% CI 1.76-3.88) compared to PPI alone 5
• Prevention of ulcer recurrence in H. pylori-positive patients who cannot undergo eradication therapy, as rebamipide reduces recurrence rates comparable to amoxicillin plus omeprazole 6

Evidence Supporting Adjunctive Use

• In H. pylori-positive gastric ulcers, rebamipide 100 mg three times daily for 7 weeks following 1 week of eradication therapy increased healing rates to 80.0% versus 66.1% with placebo (95% CI 3.1-24.7, P = 0.013) 7
• Rebamipide improves quality of ulcer healing by reducing neutrophil infiltration in ulcer scars and promoting flat scar patterns, which correlates with lower recurrence rates 6
• The drug works through multiple mechanisms: stimulating prostaglandin and mucus glycoprotein synthesis, inhibiting reactive oxygen species, and reducing inflammatory cytokines 4

Critical Management Algorithm

Step 1: Initial Assessment

• Test for H. pylori using urea breath test (88-95% sensitivity, 95-100% specificity) or stool antigen test (94% sensitivity, 92% specificity) 3
• Assess for NSAID use, aspirin, anticoagulants, and other risk factors 1
• Identify alarm symptoms (hematemesis, melena, significant weight loss, dysphagia) requiring urgent endoscopy 2

Step 2: Primary Treatment

• Start PPI monotherapy immediately at standard doses 1, 2
• Discontinue all NSAIDs immediately if possible, as this heals 95% of ulcers and reduces recurrence from 40% to 9% 1
• Initiate H. pylori eradication if positive (start after 72-96 hours of IV PPI in bleeding ulcers) 3, 1

Step 3: Consider Rebamipide Addition

• Add rebamipide 100 mg three times daily for 8 weeks if:
  • NSAIDs must be continued for valid medical reasons 4
  • Post-ESD ulcer requiring accelerated healing 5
  • H. pylori-positive with concerns about eradication compliance 6, 7

Step 4: Follow-Up

• Gastric ulcers require repeat endoscopy at 6 weeks to confirm healing and exclude malignancy 3
• Duodenal ulcers do not require routine endoscopic confirmation unless NSAIDs must be continued 3
• Confirm H. pylori eradication after treatment completion 1

Common Pitfalls to Avoid

• Do not use rebamipide as monotherapy—it is not a substitute for PPI therapy, which remains the most potent acid-suppressing agent 8
• Do not use H2-receptor antagonists instead of PPIs, as they are significantly less effective and only reduce duodenal ulcer risk, not gastric ulcer risk 1, 2
• Do not overlook H. pylori testing, as failure to eradicate leads to 40-50% recurrence rates over 10 years 9
• Do not continue NSAIDs without gastroprotection—if NSAIDs are absolutely necessary, switch to celecoxib with PPI co-therapy 1
• Do not assume rebamipide replaces eradication therapy in H. pylori-positive patients; it only reduces recurrence when eradication is not feasible 6

Special Populations

• Patients requiring continuous NSAID therapy: Maintain PPI co-therapy indefinitely and consider adding rebamipide 100 mg three times daily for enhanced gastroprotection 1, 4
• Bleeding ulcers: Administer high-dose PPI (80 mg bolus followed by 8 mg/hour infusion for 72 hours) before transitioning to oral therapy; rebamipide is not indicated in acute bleeding 3, 9
• Post-ESD patients: Combination therapy (PPI + rebamipide) for 4-8 weeks significantly improves ulcer healing compared to PPI alone 5