Treatment Options for Helicobacter Pylori and Peptic Ulcer Disease
Active Helicobacter pylori—associated ulcer
1. Treat with anti—H pylori regimen for 14 days. Treatment options:
Standard Bismuth Quadruple Therapy
• Proton pump inhibitor orally twice daily
• Bismuth subsalicylate two tablets orally four times daily
• Tetracycline 500 mg orally four times daily
• Metronidazole 500 mg three times daily (OR bismuth subcitrate potassium 140 mg / metronidazole 125 mg / tetracycline 125 mg three capsules orally four times daily)
Standard Nonbismuth Quadruple Therapy
• Proton pump inhibitor orally twice daily
• Amoxicillin 1000 mg twice daily
• Metronidazole 500 mg twice daily
• Clarithromycin 500 mg twice daily
Standard Triple Therapy (No longer recommended except in locales where clarithromycin resistance is < 15%)
• Proton pump inhibitor twice daily
• Clarithromycin 500 mg twice daily
• Amoxicillin 1 g orally twice daily (or, if penicillin allergic, metronidazole 500 mg orally twice daily)
2. After completion of course of H pylori eradication therapy, continue treatment with proton pump inhibitorl once daily for 4-6 weeks if ulcer is large (> I cm) or complicated.
3. Confirm successful eradication of H pylori with urea breath test, fecal antigen test, or endoscopy with biopsy at least 4 weeks after completion of antibiotic treatment and 1—2 weeks after proton pump inhibitor treatment.
Active ulcer not attributable to H pylori
Consider other causes: NSAIDs, Zollinger-EIIison syndrome, gastric malignancy. Treatment options:
• Proton pump inhibitors:
- Uncomplicated duodenal ulcer: treat for 4 weeks
- Uncomplicated gastric ulcer: treat for 8 weeks
• H2-receptor antagonists:
- Uncomplicated duodenal ulcer: cimetidine 800 mg, ranitidine or nizatidine 300 mg, famotidine 40 mg, orally once daily at bedtime for 6 weeks
- Uncomplicated gastric ulcer: cimetidine 400 mg, ranitidine or nizatidine 150 mg, famotidine 20 mg, orally twice daily for 8 weeks
- Complicated ulcers: proton pump inhibitors are the preferred drugs
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