What is the optimal duration of PPI therapy for healing an ulcer?

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It depends on the type of ulcer. For Helicobacter pylori-associated peptic ulcers, 7-day treatment with a proton pump inhibitor (PPI) plus 2 antibiotics heals more than 90% of ulcers and is as effective as the same regimen followed by 2 to 4 additional weeks of PPI therapy (strength of recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs]).

For peptic ulcers associated with nonsteroidal anti-inflammatory drugs (NSAIDs), 8 weeks of PPI treatment is better than 4 weeks in the case of gastric ulcers, but no more effective than 4 weeks for duodenal ulcers. (SOR: A, meta-analysis of RCTs).

For gastric ulcers resulting from endoscopic submucosal dissection, 4 weeks of PPI therapy is as effective as 8 weeks, but both regimens leave nearly a third of ulcers unhealed (SOR: B, single RCT).

For H pylori ulcers, 7 days of therapy does the trick

A 2005 meta-analysis of 6 RCTs with 862 patients compared 7 days of triple therapy with a PPI and 2 antibiotics with the same regimen followed by 2 to 4 additional weeks of PPI therapy.1 One RCT studied both duodenal and gastric ulcers; the remaining 5 assessed only duodenal ulcers. Investigators included only studies that clearly identified both H pylori eradication and ulcer healing as treatment goals and specified the number of patients treated, the number who experienced successful healing, endoscopic ulcer confirmation, and no concurrent NSAID use.

Triple therapy regimens comprised either omeprazole or esomeprazole 20 mg twice daily plus clarithromycin and either metronidazole, amoxicillin, or tinidazole for 7 days. In all studies, patients randomly assigned to receive an additional 2 to 4 weeks of PPI treatment were given omeprazole 20 mg/d.

Mean ulcer healing rates were 91% (95% confidence interval [CI], 87%-95%) for 7 days of PPI triple therapy compared with 92% (95% CI, 89%-96%) when PPI treatment was extended for an additional 2 to 4 weeks (odds ratio=1.1; 95% CI, 0.71-1.7).

Longer PPI therapy works better for NSAID-associated gastric ulcers

A 1998 meta-analysis examined 2 large RCTs that evaluated healing rates of NSAID-associated ulcers at 4 weeks and 8 weeks in 656 patients with gastric or duodenal ulcers who were treated with omeprazole 20 mg/d or 40 mg/d.2 Patients had ulcers 3 mm or larger or more than 10 erosions in the stomach or duodenum. Gastric ulcers outnumbered duodenal ulcers 2 to 1. Patients had taken continuous therapeutic doses of NSAIDs for at least 5 days per week during 2 weeks in the month preceding PPI therapy; about half were H pylori-positive.

For gastric ulcers, treatment success at 8 weeks was significantly higher at both PPI doses than at 4 weeks. The 208 patients taking the 20-mg dose showed 67% treatment success at 4 weeks and 83% at 8 weeks (P=.001). The 212 patients taking 40 mg had 67% treatment success at 4 weeks and 82% at 8 weeks (P=.002).

Duodenal ulcers showed no difference in healing at 4 and 8 weeks at either PPI dose. The 20-mg dose (116 patients) produced 84% treatment success at 4 weeks compared with 93% at 8 weeks (P=.2), and the 40-mg dose (120 patients) showed 86% treatment success at 4 weeks compared with 88% at 8 weeks (P=.8).


Evidence-based answers from the Family Physicians Inquiries Network

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