Treatment of Peptic Ulcer Disease and Nonulcer Dyspepsia

Journal of Family Practice, July, 2001 by Linda N. Meurer

TABLE 2
APPROACH TO MANAGEMENT OF UNCOMPLICATED PEPTIC ULCER DISEASE

Strength of      Treatment                 Comment
Recommendation

Patient uses
  NSAIDs:

B                Discontinue all           Relative risk of
                     NSAID therapy           ulcer complication
                     if possible             return to baseline
                                             within 2 months of
                                             discontinuation of
                                             NSAID

                 If unable to
                    discontinue
                    NSAIDs,
                    consider
                    adding:

A                * Misoprostol             Misoprostol associated
                                             with diarrhea at all
                                             doses.
A                * Double standard         Omeprazole superior
                     dose of [H.sub.2]       to misoprostol
                     blocker (eg,            for duodenal ulcers
                     ranitidine              only.
                     300 mg twice
                     daily)
A                * PPI (eg, 5
                     omeprazole 20
                     mg per day)

D                If unable to              Lower risk of ulcers
                     discontinue             and ulcer complications
                     NSAIDs, consider        than older NSAIDs, but
                     change to               no studies in patients
                     specific COX-2          with a history of
                     inhibitor               NSAID-induced ulcers.

Positive
  Helicobacter
  pylori
Test Result:

A                Combination H
                     pylori eradication
                     therapy such as
                     10 to 14 days of:
                 * PPI                     Convenient twice-daily
                                             dosing may improve
                                             compliance.
                 * Clarithromycin          Prepackaged combinations
                                             (eg, Prevpak) provides
                                             added convenience and
                                             cost.

                 * Amoxicillin(*)          Treat with another regimen
                                             not tried or quadruple
                                             therapy in case of
                                             treatment failure.

                   (see Table 3 for
                     alternative
                     effective
                     combinations)

D                Confirm eradication       Stool antigen test is
                     through noninvasive     convenient in an office
                     means or endoscopy      setting, but may
                                             continue to have
                                             false positives up
                                             to 4 weeks following
                                             eradication.

Negative
  Helicobacter
  pylori
Test Result:

(consider GI
  referral
  to help
  determine
  cause)

E                Antacids (not             Antacids are not
                     recommended)            effective over
                                             placebo.

B                Treat with either:
B                * PPI                     Long-term maintenance
                                             therapy may be
                                             required.
                 * [H.sub.2] receptor
                     agonist

PPI denotes proton pump inhibitor; NSAID, nonsteroidal
anti-inflammatory drugs; GI, gastrointestinal.