The short-term goals of peptic ulcer disease (PUD) treatment are to promote ulcer healing, prevent potential complications, and when h. pylori is present, provide an optimal environment for an effective antibiotic therapy. The long-term goals of treatment include resolving the ulcer, preventing recurrence and avoiding potential complications. The treatment plan for PUD differs by the cause (NSAID vs. non-NSAID users) and location (stomach vs. duodenum) of the ulcer. The medications used in PUD management include acid suppressants (antacids, histamine-2 receptor blockers, and proton pump inhibitors) and gastric mucosal protectants, for relief of symptoms and to promote ulcer healing, and antibiotics to eradicate h. pylori when it is present.
NSAID induced ulcers are generally treated by stopping NSAID use and providing acid suppressive therapy. Increased mucosal protection may also be included in the treatment plan in people who cannot stop taking NSAIDs. Non-NSAID induced ulcers are usually caused by h. pylori and are treated with a combination of antibiotics and acid suppressive therapy. In both NSAID and non-NSAID induced ulcers, acid suppressive therapy is given in higher doses and for a longer duration for stomach ulcers than for duodenal ulcers because stomach ulcers take longer to heal. Please refer to the text below and table (1) for details on the medications used in the treatment of PUD.
I. Acid suppressants
1. Antacids
Antacids neutralize acid in the stomach and prevent activation of pepsin. They provide short-term (45 minutes to 3 hours) relief of ulcer symptoms. Drawbacks to antacid use include side effects, such as constipation and diarrhea, and the potential to interact with other drugs.
2. Histamine-2 (H2)-receptor blockers
H2-blockers work by blocking the histamine stimulated secretion of acid by the parietal cell. Although infrequent, potential side effects include: diarrhea, headache and mental status changes in elderly persons. Patients taking cimetidine need to be especially cautious of using other prescribed and over-the-counter medications as there are a lot of drug interactions associated with this drug. The major drawback to the use of H2-blockers is the potential for development of tolerance to the acid suppression effects of the drugs.
3. Proton pump inhibitors (PPIs)
Proton pump inhibitors (PPIs) are the most potent acid-suppressing medications in use today. They block acid secretion at its source by binding directly to the proton pump which is the final step in the metabolic pathway of acid secretion. These medications may also facilitate the transport of anti- h. pylori antibiotics to the site of infection. Most people who take PPIs experience little to no side effects, but the most common potential side effects include nausea, diarrhea, abdominal pain, dizziness or headache. Patients taking omeprazole need to be especially cautious of using other medications as there are a lot of drug interactions associated with this PPI. Drug interactions may also occur with lansoprazole, but are far less frequent.
II. Gastric mucosal protectant
Sucralfate forms a physical barrier over ulcerated tissue to protect it from aggressive factors. The drug is not absorbed into the body to any significant extent and is not an acid suppressant. Side effects with sucralfate are uncommon, but may include constipation, nausea, flatulence and gastric discomfort. Sucralfate may reduce the absorption of other medications, so it is a good idea to separate this medication from others by at least 2 hours.
III. Antibiotics
Antibiotics are used to eradicate h. pylori when it is present. The antibiotics that are commonly used for this purpose include bismuth subsalicylate, metronidazole, amoxicillin, tetracycline and clarithromycin. Important patient information about these antibiotics is listed below.
| Bismuth subsalicylate |
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Shake the liquid well before using; |
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Chew tablets or allow to dissolve in the mouth. Do not shallow whole; |
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May cause dark discoloration of tongue or stool. |
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| Metronidazole |
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May cause harmless discoloration of urine; |
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Avoid alcoholic beverages for the entire time you are taking this medication; |
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You may notice a metallic taste in your mouth; |
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Take with food to decrease stomach upset. |
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| Amoxicillin |
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You can take this medication with or without food; |
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Females using oral contraceptives should use an additional method of contraception during treatment. |
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| Tetracycline |
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Take this medication 1 hour before or 2 hours after meals; |
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Do not take any antacids, iron, or dairy products for 2 hours before or after this medication; |
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Avoid prolonged exposure to sunlight and use sunscreen when if you are going to be out in the sun; |
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Females using oral contraceptives should use an additional method of contraception during treatment. |
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| Clarithromycin |
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You can take this medication with or without food; |
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You may notice an abnormal taste in your mouth. |
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If you are found to have h. pylori infection, your treatment regimen should include at least two of these antibiotics. Treatment with just one antibiotic has been found to be highly ineffective in eliminating the organism. It is very important that you adhere to the prescribed treatment and finish the entire course of antibiotics in order to aid in successful eradication of h. pylori. Please refer to table (2) for a summary of commonly used anti-h. pylori treatment regimens. |
