What is the treatment for Peptic Ulcer Disease (PUD)?

From the Guidelines

For peptic ulcer disease (PUD) treatment, I recommend a combination approach targeting both symptom relief and underlying causes, starting with a proton pump inhibitor (PPI) such as omeprazole 20mg or pantoprazole 40mg once daily for 4-8 weeks, and adding antibiotic therapy with clarithromycin 500mg twice daily, amoxicillin 1000mg twice daily, and continuing the PPI twice daily for 14 days (triple therapy) if H. pylori infection is present, as supported by the most recent guidelines 1.

Treatment Approach

The treatment approach should prioritize the eradication of H. pylori infection if present, as it is a major cause of PUD. The use of triple therapy, including a PPI, clarithromycin, and amoxicillin, is recommended for 14 days 1. For NSAID-induced ulcers, discontinuing the NSAID if possible and using the PPI for healing is recommended.

Pharmacological Regimen

The pharmacological regimen should include a PPI, such as omeprazole or pantoprazole, at a standard dose twice a day, and antibiotic therapy if H. pylori infection is present. The use of sucralfate or H2-receptor antagonists is not recommended as first-line therapy due to their limited efficacy compared to PPIs 1.

Lifestyle Modifications

Lifestyle modifications are important to prevent recurrence of PUD. Patients should avoid alcohol, smoking, spicy foods, and NSAIDs, and eat smaller, more frequent meals. Treatment success should be confirmed with follow-up testing for H. pylori eradication if that was the cause.

Recent Guidelines

Recent guidelines suggest that potassium-competitive acid blockers (P-CABs) may be useful in PPI treatment failures of ulcers, but their use as first-line therapy is not recommended due to higher costs and limited availability 1. However, P-CABs may be noninferior to PPIs for secondary peptic ulcer prophylaxis, and their rapid and potent acid inhibition raises the possibility of their utility in patients with bleeding gastroduodenal ulcers and high-risk stigmata.

Key Points

• Start with a PPI such as omeprazole 20mg or pantoprazole 40mg once daily for 4-8 weeks.
• Add antibiotic therapy with clarithromycin 500mg twice daily, amoxicillin 1000mg twice daily, and continue the PPI twice daily for 14 days (triple therapy) if H. pylori infection is present.
• Discontinue NSAID use if possible and use the PPI for healing in NSAID-induced ulcers.
• Lifestyle modifications, such as avoiding alcohol, smoking, spicy foods, and NSAIDs, and eating smaller, more frequent meals, are important to prevent recurrence of PUD.

From the FDA Drug Label

14.2 H. pylori Eradication in Patients with Duodenal Ulcer Disease Triple Therapy (omeprazole/clarithromycin/amoxicillin) The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori. The treatment for PUD (Peptic Ulcer Disease), specifically for H. pylori eradication, is triple therapy consisting of omeprazole, clarithromycin, and amoxicillin.

• The dose regimen is omeprazole 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days.
• This treatment has been shown to be effective in eradicating H. pylori and healing duodenal ulcers 2.

From the Research

Peptic Ulcer Disease Treatment

• The primary treatment for peptic ulcer disease is acid blocking with proton pump inhibitors, such as omeprazole or lansoprazole 3.
• Eradication of H. pylori infection can decrease peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2% 3.
• Discontinuing NSAIDs can heal 95% of ulcers identified on endoscopy and reduce recurrence from 40% to 9% 3.
• When discontinuing an NSAID is not desirable, changing the NSAID, adding a proton pump inhibitor, and eradicating H. pylori can reduce recurrence rates 3.

Treatment Options

• Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks, but gastric ulcers larger than 2 cm may require 8 weeks of treatment 3.
• Proton pump inhibitors, such as lansoprazole or omeprazole, can be used to treat complicated peptic ulcer disease and upper gastrointestinal tract bleeding 4.
• Maintenance therapy with H2-blockers or sucralfate can reduce the relapses of duodenal ulcer disease and gastric ulcer disease 5.
• Elimination of H. pylori infection with antibiotics may reduce recurrent ulcer disease and negate the need for maintenance therapy 5.

Role of Proton Pump Inhibitors

• Proton pump inhibitors play an important role in the treatment of both H. pylori-negative and H. pylori-positive peptic ulcers, as well as in upper gastrointestinal tract bleeding 4.
• Proton pump inhibitors can heal a significantly higher percentage of peptic ulcers in eight weeks than histamine H2-receptor antagonists 4.
• Maintenance therapy with proton pump inhibitors, such as lansoprazole or omeprazole, can reduce ulcer recurrence 4.

Diagnosis and Treatment

• Timely diagnosis and treatment of peptic ulcer disease and its sequelae are crucial in order to minimize associated morbidity and mortality 6.
• The role of proton pump inhibitors in the management of peptic ulcer disease, as well as the latest guidelines about the diagnosis and management of H. pylori, are important considerations in treatment 6.
• Endoscopic intervention for peptic ulcer-related bleeding is a key aspect of treatment 6.