What is the most common drug used for peptic ulcer disease: Proton Pump Inhibitors (PPI) or Helicobacter pylori (H. pylori) eradication or Histamine-2 (H2) blockers or prokinetics?

From the Guidelines

Proton pump inhibitors (PPIs) are the most common drugs used for peptic ulcer disease, and the most recent guidelines recommend their use in combination with antibiotics for H. pylori eradication. The treatment of peptic ulcer disease (PUD) has evolved over the years, with a focus on the eradication of H. pylori infection, which is a major cause of PUD. According to the most recent guidelines, including the 2020 WSES guidelines 1, the first-line treatment for H. pylori-positive patients is a standard triple therapy regimen consisting of a PPI, amoxicillin, and clarithromycin.

Key Points to Consider

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1.
• Sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) should be considered in selected cases, if compliance to the scheduled regimen can be maintained, and if clarithromycin high resistance is detected 1.
• If any of these regimens failed, a second-line therapy is represented by a 10-day levofloxacin-amoxicillin triple therapy 1.
• H2 blockers (like ranitidine and famotidine) are less potent than PPIs and are now considered second-line therapy.
• Prokinetics (like metoclopramide) may be added to improve symptoms but aren't primary treatments for ulcers.

Treatment Recommendations

• For H. pylori-associated ulcers, treatment typically involves a combination therapy known as triple therapy: a PPI plus two antibiotics (usually amoxicillin and clarithromycin) for 10-14 days.
• For non-H. pylori ulcers, PPIs alone are typically prescribed for 4-8 weeks.
• The most recent and highest quality study recommends starting standard triple therapy after 72–96 h of intravenous administration of PPI and to administer it for 14 days 1.

Rationale for Recommendations

The rationale for these recommendations is based on the most recent and highest quality evidence, which prioritizes the use of PPIs in combination with antibiotics for H. pylori eradication. This approach has been shown to be effective in preventing recurrent bleeding and improving outcomes in patients with peptic ulcer disease. The use of PPIs and antibiotics is supported by the 2020 WSES guidelines 1, which provide a strong recommendation based on moderate-quality evidence.

From the Research

Treatment Options for Peptic Ulcer Disease

The most common drugs used for peptic ulcer disease include:

• Proton-pump inhibitors (PPIs) 2, 3, 4, 5
• H. pylori eradication therapy 2, 3, 4, 5
• H2 blockers 2, 4
• Prokinetics are not commonly mentioned in the provided studies as a primary treatment for peptic ulcer disease

Efficacy of Different Regimens

• PPI-based triple therapies are effective in H. pylori eradication, with mean eradication rates ranging from 71.9% to 83.8% 5
• High-dose PPI regimens may not be significantly more effective than lower-dose regimens in reducing mortality, rebleeding, or surgical interventions in patients with acute peptic ulcer bleeding 6
• Omeprazole is a well-studied PPI that is effective in eradicating H. pylori infections and treating gastroesophageal reflux disease (GORD) and NSAID-induced gastrointestinal damage 4

Comparison of Treatment Options

• PPIs are more effective than H2 blockers in healing peptic ulcers and preventing recurrence 2, 4
• H. pylori eradication therapy is essential for treating peptic ulcer disease caused by H. pylori infection 2, 3, 4, 5
• The choice of treatment regimen depends on various factors, including the presence of H. pylori infection, NSAID use, and the severity of symptoms 2, 3, 4, 5, 6