What is the most common drug used for peptic ulcer disease, Proton Pump Inhibitors (PPI) or Helicobacter pylori (H. pylori) eradication?

From the Guidelines

The most common drug used for peptic ulcer disease is a Proton Pump Inhibitor (PPI) as part of H. pylori eradication therapy, specifically standard triple therapy with amoxicillin, clarithromycin, and a PPI, as recommended by recent guidelines 1. When considering treatment options for peptic ulcer disease, it's essential to prioritize H. pylori eradication therapy, especially in patients with positive tests for HP infection, as it significantly reduces the risk of recurrent bleeding and ulcer recurrence.

• The standard triple therapy regimen, which includes a PPI, amoxicillin, and clarithromycin, is recommended as first-line therapy if low clarithromycin resistance is present, with a strong recommendation based on moderate-quality evidence 1.
• The suggested doses for standard triple therapy are:
  • PPI standard dose twice a day
  • Clarithromycin 500 mg twice a day
  • Amoxicillin 1000 mg twice a day
• In cases where clarithromycin resistance is high, sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) may be considered, with a strong recommendation based on low-quality evidence 1.
• If first-line therapy fails, a 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy, with a strong recommendation based on moderate-quality evidence 1. The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, and all patients with peptic ulcers should be tested for H. pylori to determine the best course of treatment 1.

From the FDA Drug Label

The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori. Table 9: Per-Protocol and Intent-to-Treat H pylori Eradication Rates % of Patients Cured [95% Confidence Interval] Omeprazole + clarithromycin + amoxicillin Study 1 773 64, 86 (n = 64) Study 2 783 67, 88 (n = 65) Study 3 90380, 96 (n = 69) The combination of omeprazole and clarithromycin was effective in eradicating H. pylori. Table 10: H. pylori Eradication Rates (Per-Protocol Analysis at 4 to 6 Weeks) % of Patients Cured [95% Confidence Interval] Omeprazole + Clarithromycin U. S. Studies Study 4 74 60, 851,2 (n = 53) Study 5 64 51, 76 1,2 (n = 61) Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. The most common drug used for peptic ulcer disease is a Proton Pump Inhibitor (PPI), such as omeprazole, in combination with antibiotics like amoxicillin and clarithromycin for H. pylori eradication.

• PPIs are used to reduce stomach acid and allow the stomach lining to heal.
• H. pylori eradication is typically achieved with a combination of two antibiotics, such as amoxicillin and clarithromycin, and a PPI.
• The choice of treatment depends on the presence of H. pylori infection and the severity of the peptic ulcer disease. 2 3

From the Research

Peptic Ulcer Disease Treatment

The most common treatments for peptic ulcer disease (PUD) are proton pump inhibitors (PPIs) and H. pylori eradication therapy.

• PPIs, such as omeprazole and lansoprazole, are used to reduce stomach acid and allow ulcers to heal 4, 5, 6, 7.
• H. pylori eradication therapy typically involves a combination of antibiotics, such as clarithromycin and amoxicillin, and a PPI 4, 5, 7, 8.

H. pylori Eradication vs. PPIs

• Eradicating H. pylori infection can reduce the likelihood of peptic ulcers by one-half in NSAID users 4.
• PPIs 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 5.
• Discontinuing NSAIDs can heal 95% of ulcers identified on endoscopy and reduce recurrence from 40% to 9% 5.

Treatment Recommendations

• The H. pylori test-and-treat strategy is the mainstay of outpatient management for patients with dyspepsia without alarm symptoms 4.
• Patients with H. pylori infection should be treated with antimicrobial therapy to eradicate the infection, and PPIs can be used to reduce stomach acid and allow ulcers to heal 4, 6, 7, 8.
• For patients who require continuous NSAID therapy, PPIs have been shown to heal a significantly higher percentage of peptic ulcers in eight weeks than histamine H2-receptor antagonists, and maintenance therapy with either lansoprazole or omeprazole reduces ulcer recurrence 6.