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). [48] 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.
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+.
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) when administering 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.
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) when administering 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.
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.
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.
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).
H2-Receptor Antagonists
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.
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.
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.
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.
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. As of April 1, 2020, ranitidine was withdrawn from the market due to an increasing number of products containing the contaminant known as N-Nitrosodimethylamine (NDMA), a possible carcinogen.
Antimicrobials
Class Summary
Antimicrobial agents exert an antibacterial effect on H pylori.
Amoxicillin (Amoxil, Biomox, Trimox)
This is a component of drug combination therapy that effectively treats duodenal ulcer or gastric ulcer 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.
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 ulcer 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 amoxicillin in proton pump inhibitor–based triple therapy.
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.
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.
Antidiarrheal Agents
Class Summary
Antidiarrheal agents may have antisecretory and antimicrobial action.
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.
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.
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.
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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Peptic ulcer disease. Vagal innervation of the stomach.
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Peptic ulcer disease. Gastric ulcer with a punched-out ulcer base and whitish fibrinoid exudates.
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Peptic ulcer disease. Gastric ulcer (lesser curvature) with a punched-out ulcer base with a whitish exudate.
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Peptic ulcer disease. Gastric cancer. Note the irregular heaped-up overhanging margins.
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Peptic ulcer disease. Gastric cancer with an ulcerated mass.
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Peptic ulcer disease. Gross pathology specimen of a gastric ulcer.
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Peptic ulcer disease. Gastric cancer with an ulcerated mass.
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Peptic ulcer disease. Endoscopic view of an ulcer (at the upper center) in the wall of the duodenum, the first part of the small intestine. This ulcer is an open sore. Image courtesy of Science Source | Gastrolab.
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Peptic ulcer disease. Duodenal ulcer in a 65-year-old man with osteoarthritis who presented with hematemesis and melena. The patient took naproxen on a daily basis.
