Which tablet should be given as first‑line therapy for a suspected duodenal ulcer?

First-Line Tablet for Suspected Duodenal Ulcer

Start a proton pump inhibitor (PPI) immediately: omeprazole 20 mg once daily, lansoprazole 30 mg once daily, or pantoprazole 40 mg once daily for 4 weeks. 1, 2, 3

Initial Pharmacological Management

PPIs are the first-line therapy for duodenal ulcers, with standard doses healing over 90% of ulcers within 4 weeks. 4, 5 The FDA-approved regimen for active duodenal ulcer is omeprazole 20 mg once daily for 4 weeks, with most patients healing within this timeframe. 3 Alternative equivalent options include lansoprazole 30 mg daily or pantoprazole 40 mg daily. 4, 5

• Administer the PPI before meals to maximize acid suppression during the postprandial period when acid secretion peaks. 3
• PPIs irreversibly inhibit the H+/K+ ATPase proton pump and are significantly more effective than H2-receptor antagonists for ulcer healing. 4, 6
• If the patient does not heal after 4 weeks, an additional 4 weeks of therapy may be given. 3

Critical Next Steps: H. pylori Testing

Test all duodenal ulcer patients for Helicobacter pylori infection immediately, as this fundamentally changes the treatment approach and prevents recurrence. 1, 2

• Use the urea breath test (sensitivity 88-95%, specificity 95-100%) or stool antigen test (sensitivity 94%, specificity 92%) as preferred non-invasive methods. 1
• If H. pylori is positive, add eradication therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10-14 days. 1, 3
• Eradication reduces ulcer recurrence from 50-60% to 0-2%, making this step critical for long-term outcomes. 1
• Confirm eradication after completing treatment to ensure successful therapy. 1, 2

NSAID-Associated Ulcers

If the patient is taking NSAIDs or aspirin, discontinue them immediately whenever clinically feasible, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 1, 2

• If NSAIDs must be continued, switch to a selective COX-2 inhibitor (celecoxib) or lower-risk NSAID (ibuprofen) combined with long-term PPI therapy. 1
• Test for and eradicate H. pylori even in NSAID users, as eradication reduces peptic ulcer likelihood by 50%. 1

Common Pitfalls to Avoid

• Never skip H. pylori testing—this single omission accounts for the majority of treatment failures and recurrences, with failure to eradicate leading to 40-50% recurrence rates over 10 years. 2
• Do not use H2-receptor antagonists as first-line therapy—they are significantly less effective than PPIs for duodenal ulcer healing. 4, 6
• For patients with alarm features (hematemesis, melena, hemodynamic instability, severe abdominal pain), urgent endoscopy is required—PPIs should not replace endoscopy in active bleeding. 1, 2
• Endoscopic confirmation of duodenal ulcer healing after H. pylori eradication is probably not necessary unless the patient must continue NSAIDs. 7

Cost-Effectiveness Consideration

Among PPIs, pantoprazole 40 mg daily appears to be the most cost-effective option while maintaining equivalent efficacy and safety to other PPIs. 5