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Treatments and drugs
By Mayo Clinic staffBecause many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment:
- Kill the bacteria.
- Reduce the level of acid in your digestive system to relieve pain and encourage healing.
Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications:
- Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. For the treatment to work, follow your doctor's instructions precisely. Antibiotics prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have been designed specifically for the treatment of H. pylori infection. You'll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed along with antibiotics generally are taken for a longer period.
- Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).
- Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.
- Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprazole (Protonix) can be taken orally or administered intravenously in the hospital. Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic ulcers. If you're admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture. Ask your doctor if you need a calcium supplement while taking these medications.
- Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol).
If H. pylori isn't identified in your system, then it's likely that your ulcer is due to NSAIDs — which you should stop using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs.
Ulcers that fail to heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. These reasons may include:
- Not taking medications according to directions.
- The fact that some types of H. pylori are resistant to antibiotics.
- Regular use of tobacco.
- Regular use of alcohol.
- Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People may be unaware that a medication they're taking contains an NSAID.
Less often, refractory ulcers may be a result of:
- Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
- An infection other than H. pylori
- Stomach cancer
- Other diseases, including cirrhosis and chronic obstructive pulmonary disorder (COPD)
Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn't respond to aggressive drug treatment.
- H. pylori and peptic ulcer. National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/. Accessed Oct. 16, 2008.
- What I need to know about peptic ulcers. National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/pepticulcers_ez/. Accessed Oct. 16, 2008.
- Peptic ulcer disease. American Gastroenterological Association. http://www.gastro.org/frame-templates/print_template.cfm. Accessed Oct. 16, 2008.
- Soll AH. Peptic ulcer disease: Genetic, environmental, and psychological risk factors and pathogenesis. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2008.
- Soll AH. Overview of peptic ulcer: Epidemiology and major causes. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2008.
- Lau JY. Omeprazole before endoscopy in patients with gastrointestinal bleeding. New England Journal of Medicine. 2007;356(16):1631-1640.
- Yang YX. Long-term proton pump inhibitor therapy and risk of hip fracture. Journal of the American Medical Association. 2007;296(24):2947-2953.
- Soll AH. Overview of the natural history and treatment of peptic ulcer disease. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2008.
- Soll AH. Treatment of refractory or recurrent peptic ulcer disease. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2008.
- Soll AH. Unusual causes of and diseases associated with peptic ulcer disease. http://www.uptodate.com/home/index.html. Accessed Oct. 16, 2008.
- Cryer B, et al. Peptic ulcer disease. In: Feldman M, et al. Sleisenger & Fortran's Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa. Saunders Elsevier. http://www.mdconsult.com/das/book/body/113080343-3/781010342/1389/364.html#4-u1.0-B1-4160-0245-6..50055-X--cesec29_2206. Accessed Nov. 3, 2008.
