Peptic Ulcer Disease Medication

  • Author: BS Anand, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 20, 2011
 

Medication Summary

The goals of pharmacotherapy are to eradicate H pylori infection, to reduce morbidity, and to prevent complications in patients with peptic ulcers. Acid suppression is the general pharmacologic principle of medical management of acute bleeding from a peptic ulcer, using histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs).[33] Both classes are available in intravenous or oral preparations. Discontinuation of NSAIDs is paramount, if it is clinically feasible. For patients who must continue with their NSAIDs, PPI maintenance is recommended to prevent recurrences even after eradication of H pylori.

The recommended primary therapy for H pylori infection is proton pump inhibitor (PPI)–based triple therapy. Antacids or a GI cocktail (typically an antacid with an anesthetic such as viscous lidocaine and/or an antispasmodic) may be used as symptomatic therapy in the ED. Maintenance treatment with antisecretory medications (eg, H2 blockers, PPIs) for 1 year is indicated in high-risk patients. High-risk patients include those with recurrent ulcers and those with complicated or giant ulcers. If H pylori eradication is not achieved despite repeat treatment, maintenance antisecretory therapy should be recommended. Patients with refractory ulcers may continue receiving once-daily PPI therapy indefinitely. In this setting, if H pylori is absent, consider a secondary cause of duodenal ulcer, such as Zollinger-Ellison syndrome

Primary prevention of NSAID-induced ulcers includes avoiding unnecessary use of NSAIDs, using acetaminophen or nonacetylated salicylates when possible, and using the lowest effective dose of an NSAID and switching to less toxic NSAIDs.

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Proton Pump Inhibitors

Class Summary

PPIs are inhibitors of the gastric H+/K+ -ATPase (proton pump) enzyme system, which catalyzes the exchange of H+ and K+.

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Omeprazole (Prilosec)

 

Omeprazole decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump. It usually is given with clarithromycin and amoxicillin (or metronidazole if the patient is allergic to penicillin) if giving proton pump inhibitor–based triple therapy. It might decrease the incidence of NSAID-induced peptic ulcers and can be used to help prevent peptic ulcers in long-term NSAID users at high risk.

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Lansoprazole (Prevacid)

 

Lansoprazole decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump. It usually is given with clarithromycin and amoxicillin (or metronidazole if the patient is allergic to penicillin) if giving proton pump inhibitor–based triple therapy. It might decrease the incidence of NSAID-induced peptic ulcers and can be used to help prevent peptic ulcers in long-term NSAID users at high risk.

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Rabeprazole (Aciphex)

 

Rabeprazole decreases gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump. It is used for short-term (4-8 wk) treatment and relief of symptomatic erosive or ulcerative gastroesophageal reflux disease. Patients not healed after 8 weeks should consider an additional 8-week course.

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Esomeprazole (Nexium)

 

Esomeprazole is an S-isomer of omeprazole. It inhibits gastric acid secretion by inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells. It is used in severe cases and in patients who have not responded to H2 antagonist therapy. Esomeprazole is used for up to 4 weeks to treat and relieve symptoms of active duodenal ulcers, and it may be used for up to 8 weeks to treat all grades of erosive esophagitis.

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Pantoprazole (Protonix)

 

Pantoprazole suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells. Use of the intravenous preparation has only been studied for short-term use (ie, 7-10 d).

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H2 Receptor Blockers

Class Summary

H2 blocker antihistamine agents are used in the short-term treatment of an active duodenal ulcer and as prophylaxis in the long term.

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Cimetidine (Tagamet)

 

Cimetidine can be used as primary therapy to heal ulcers not associated with H pylori infection. The duration of treatment is 6-8 weeks. A longer treatment course might be required for gastric ulcers.

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Famotidine (Pepcid)

 

Famotidine competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.

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Nizatidine (Axid)

 

Nizatidine competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.

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Ranitidine (Zantac)

 

Ranitidine inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.

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Antimicrobials

Class Summary

Antimicrobial agents exert an antibacterial effect on H pylori.

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Amoxicillin (Amoxil, Biomox, Trimox)

 

This is a component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcers associated with H pylori infection. It interferes with the synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Administer with omeprazole or lansoprazole plus clarithromycin in proton pump inhibitor–based triple therapy.

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Clarithromycin (Biaxin)

 

This is a semisynthetic macrolide antibiotic that reversibly binds to the P site of the 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating the dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition. This component of drug combination therapy effectively treats duodenal ulcer or gastric ulcers associated with H pylori infection. It interferes with the synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Administer with omeprazole or lansoprazole plus clarithromycin in proton pump inhibitor–based triple therapy.

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Tetracycline (Sumycin)

 

Component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer associated with H pylori infection. Usually used in combination with bismuth subsalicylate and metronidazole.

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Metronidazole (Flagyl, Flagyl ER)

 

This is a component of drug combination therapy that effectively treats duodenal ulcers or gastric ulcers associated with H pylori infection. It is active against various anaerobic bacteria and protozoa. It appears to be absorbed into cells. The intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.

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Antidiarrheal Agents

Class Summary

Antidiarrheal agents may have antisecretory and antimicrobial action.

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Bismuth subsalicylate (Pepto Bismol, Pink Bismuth, Kaopectate Extra Strength)

 

This is a highly insoluble salt of trivalent bismuth and salicylic acid. Greater than 80% of salicylic acid is absorbed from oral doses of bismuth subsalicylate chewable tablets. It controls diarrhea by reducing fluid secretion into the intestinal lumen, by binding bacterial toxins, or by acting as an antimicrobial agent.

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Cytoprotective Agents

Class Summary

Cytoprotective agents stimulate mucus production and enhance blood flow throughout the lining of the gastrointestinal tract. These agents also work by forming a coating that protects the ulcerated tissue. Examples of cytoprotective agents include misoprostol and sucralfate.

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Misoprostol (Cytotec)

 

Misoprostol is a prostaglandin analog that can be used to decrease the incidence of peptic ulcers and complications in long-term NSAID users at high risk.

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Sucralfate (Carafate)

 

Sucralfate binds with positively charged proteins in exudates and forms a viscous adhesive substance that protects the GI lining against pepsin, peptic acid, and bile salts. It is used for short-term management of ulcers.

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Contributor Information and Disclosures
Author

BS Anand, MD  Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Simmy Bank, MD  Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Waqar A Qureshi, MD  Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Shane M Devlin, MD, FRCP(C)  Clinical Assistant Professor, Department of Internal Medicine, Peter Lougheed Center, University of Calgary, Canada

Shane M Devlin, MD, FRCP(C) is a member of the following medical societies: American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Sanjeeb Shrestha, MD  Consulting Staff, Division of Gastroenterology, Gastroenterology Care Consultants

Sanjeeb Shrestha, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

David Greenwald, MD  Associate Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Daryl Lau, MD, MPH, MSc, FRCP(C)  Director of Translational Liver Research, Liver Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School

Daryl Lau, MD, MPH, MSc, FRCP(C) is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

B UK Li, MD  Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD  Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

George T Fantry, MD  Director of Clinical Gastroenterology, Department of Internal Medicine, Division of Gastroenterology, Associate Professor, University of Maryland School of Medicine

George T Fantry, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Nothing to disclose.

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Chris A Liacouras  MD, Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Faisal Aziz, MD  Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine

Faisal Aziz, MD is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Tri H Le, MD  Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center

Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Jay A Yelon, DO, FACS  Associate Professor of Surgery and Anesthesiology, Program Director, Surgical Critical Care Fellowship, New York Medical College; Chief, Division of Trauma and Surgical Critical Care, Westchester Medical Center

Jay A Yelon, DO, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons, American Trauma Society, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Pan American Trauma Society, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Surgical Infection Society

Disclosure: Nothing to disclose.

Philip Shayne  MD, Associate Professor, Program Director and Vice Chair for Education, Department of Emergency Medicine, Emory University School of Medicine

Philip Shayne is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ameesh Shah, MD  Assistant Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Memorial Hospital

Ameesh Shah, MD is a member of the following medical societies: North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Harsh Grewal, MD, FACS, FAAP  Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University School of Medicine

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

Alan BR Thomson, MD  Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Mutaz I Sultan, MBChB  Instructor and Fellow, Department of Pediatrics, Division of Gastroenterology and Nutrition, Medical College of Wisconsin, Children's Hospital

Mutaz I Sultan, MBChB is a member of the following medical societies: American Gastroenterological Association and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Wendi S Miller, MD  Resident Physician, Department of Emergency Medicine, Emory University School of Medicine

Wendi S Miller, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Southern Medical Association

Disclosure: Nothing to disclose.

Erick F Rivas, MD, PT  Resident Physician, Department of Surgery, Michigan State University College of Human Medicine

Erick F Rivas, MD, PT is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Juda Zvi Jona  MD, FAAP(s), FACS, EUPSA, Clinical Professor of Surgery, Michigan State University College of Human Medicine; Clinical Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Attending Senior Surgeon, Director of Pediatric Surgery Service, Surgical Executive Committee, Sparrow Hospital

Juda Zvi Jona is a member of the following medical societies: Alpha Omega Alpha, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, British Association of Paediatric Surgeons, Central Surgical Association, Children's Oncology Group, and International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Specialty Editor Board

Terence David Lewis, MBBS, FRACP, FRCPC, FACP  Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center

Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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Vagal innervation of stomach.
Gastric ulcer with punched-out ulcer base with whitish fibrinoid exudates.
Gastric ulcer (lesser curvature) with punched-out ulcer base with whitish exudate.
Gastric cancer. Note the irregular heaped up overhanging margins.
Gastric cancer with ulcerated mass.
Gross pathology of a gastric ulcer.
Gastric cancer with ulcerated mass.
Duodenal ulcer in a 35-year-old woman who presented with tarry stools and a hemoglobin level of 75 g/L.
Duodenal ulcer in a 65-year-old man with osteoarthritis who presented with hematemesis and melena stools. The patient took naproxen on a daily basis.
 
 
 
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