Peptic Ulcers

Description An in-depth report on the causes, diagnosis, treatment, and prevention of stomach and GI ulcers.

Alternative Names Duodenal Ulcers; Gastric Ulcers; H. Pylori; Nonsteroidal Anti-inflammatory Drugs, or NSAIDs

Medications The following drugs are sometimes used in the treatments of peptic ulcers caused by either NSAIDs or H. pylori. They are described in alphabetical order. Antacids Many antacids are available without prescription and are the first drugs recommended to relieve heartburn and mild dyspepsia. They play no major role in either prevention or healing of ulcers but help in the following ways: All of the many brands available rely on various combinations of three basic compounds, magnesium, calcium, or aluminum, which neutralize the acid in the stomach. They may also defend the stomach by increasing acid-buffering bicarbonate and mucus secretion. It is generally believed that liquid antacids work faster and are more potent than tablets, although some evidence suggests that both forms work equally well.

Proton-Pump Inhibitors (PPIs)

Actions Against Ulcers. Proton-pump inhibitors (PPIs) are the drugs of choice for managing patients with peptic ulcers from any cause. They suppress the production of stomach acid. These agents work by inhibiting the molecule in the stomach glands that is responsible for acid secretion, which is called the gastric acid pump.

PPIs can be used as part of a multi-drug regimen for H. pylori or used alone for preventing and healing NSAID-related ulcers. They are even useful in the treatment of ulcers caused by Zollinger-Ellison syndrome. (Of note, certain individuals carry a gene that regulates an enzyme called CYP2C19 that reduces the effectiveness of proton-pump inhibitors. This gene may be present in between 18% and 20% of Asians, who may not respond as well to these agents.)

Standard Brands. The standard PPI for ulcers has been omeprazole (Prilosec). In fact, it has been recommended for over-the-counter use. Other newer agents include lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), and pantoprazole (Protonix). All are available orally. Pantoprazole is also available as an injection and lansoprazole as a suspension, which may be useful for patients who cannot take oral medications. In a comparison study of these agents, esomeprazole was superior in treating healing injuries in the esophagus that caused gastroesophageal reflux disease (GERD). It is not known yet, however, whether any individual PPI has superior advantages for treating ulcers.

Adverse Effects. Proton-pump inhibitors may pose the following concerns:

Side effects are uncommon but may include headache, diarrhea, constipation, nausea, and itching.

• Proton-pump inhibitors should be avoided by pregnant women and nursing mothers, although recent studies suggest that they do not pose an increased risk of birth defects.
• They may interact with certain drugs, such as antiseizure agents (e.g., phenytoin), anti-anxiety drugs (e.g., diazepam), and blood thinners (e.g., warfarin).
• Long-term use of high-dose PPIs may produce vitamin B12 deficiencies, but studies are needed to confirm any significance of this risk.
• The long-term use of proton-pump inhibitors by people with H. pylori may, in theory at least, reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach). This condition, in turn, is a risk factor for stomach cancer. To compound concerns, long-term use of PPIs may mask symptoms of stomach cancer and so delay a diagnosis. To date, however, there have been no reports of an increased risk of stomach cancer with long-term use of these drugs.

Sucralfate

Sucralfate (Carafate) seems to work by adhering to the ulcer crater and protecting it from further damage by stomach acid and pepsin. It also promotes the defensive processes of the stomach. Sucralfate has an ulcer-healing rate similar to that of H2 blockers. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate does interact with a wide variety of drugs, including warfarin, phenytoin, and tetracycline.

Experimental Agents

Ecabet is a unique anti-ulcer agent that is showing promise in early studies. It acts on the mucus lining of the stomach and has anti-bacterial activity.