summary of interventions for peptic ulcer disease (NICE)

Last reviewed 01/2018

Summary of Interventions for peptic ulcer disease

• H pylori eradication therapy should be offered to people who have tested positive for H pylori and who have peptic ulcer disease
• for people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI (table 1) or H2RA therapy for 8 weeks and, if H pylori is present, subsequently offer eradication therapy
• if peptic ulcer (gastric or duodenal) and H pylori then offer retesting for H pylori 6 to 8 weeks after beginning treatment, depending on the size of the lesion
• full-dose PPI (table 1) or H2RA therapy for 4 to 8 weeks should be offered to people who have tested negative for H pylori who are not taking NSAIDs
• for people continuing to take NSAIDs after a peptic ulcer has healed, discuss the potential harm from NSAID treatment. Review the need for NSAID use regularly (at least every 6 months) and offer a trial of use on a limited, 'as required' basis. The clinician should consider reducing the dose, substituting an NSAID with paracetamol, or using an alternative analgesic or low-dose ibuprofen (1.2 g daily)
• if a person at high risk (previous ulceration) and for whom NSAID continuation is necessary, offer gastric protection or consider substitution with a cyclooxygenase (COX)-2-selective NSAID
• if unhealed ulcer then
  • exclude non-adherence, malignancy, failure to detect H pylori, inadvertent NSAID use, other ulcer-inducing medication and rare causes such as Zollinger-Ellison syndrome or Crohn's disease
• if symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to control symptoms. Discuss using the treatment on an 'as required' basis with people to manage their own symptoms

Table 1: PPI doses

* lower than the licensed starting dose for esomeprazole in GORD, which is 40 mg, but considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of doserelated effects, NICE classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.

**off-label dose for GORD

***40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to omeprazole 20 mg.

Reference:

• NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both