Drugs for Peptic Ulcer
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Direct answer
Acid suppression to a pH above roughly 4 for most of the day is what heals peptic ulcers, and proton pump inhibitors achieve it best: omeprazole, pantoprazole or esomeprazole taken 30–60 minutes before breakfast, 4–8 weeks for duodenal and 8 weeks for gastric ulcers. Helicobacter pylori eradication needs double-time antibiotics — a 14-day regimen of a PPI twice daily with amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily — but because clarithromycin resistance across much of India exceeds the 15 per cent threshold, bismuth quadruple therapy (PPI, bismuth, tetracycline, metronidazole) or concomitant regimens are increasingly preferred per current guidance. NSAID ulcers demand drug withdrawal or gastroprotection with a PPI or misoprostol 200 µg four times daily, the latter contraindicated in pregnancy because it is an abortifacient. Confirmation of H. pylori cure requires a urea breath test or stool antigen at least four weeks after antibiotics, off PPI for 1–2 weeks.
What you must remember
- PPI pharmacology: irreversibly inhibit the parietal-cell H+/K+-ATPase; activate only in acid — hence take before meals; full effect needs 3–5 days; long-term concerns include hypomagnesaemia, B12 deficiency, C. difficile association and fracture risk.
- H. pylori regimen (classic triple): PPI bid + clarithromycin 500 mg bid + amoxicillin 1 g bid for 14 days; penicillin allergy substitutes metronidazole; salvage regimens use levofloxacin or bismuth quadruple therapy.
- Indian resistance reality: clarithromycin and metronidazole resistance is high across most of India, pushing guidelines toward 14-day bismuth quadruple or concomitant therapy — a genuinely Indian prescribing fact.
- H2 blockers (famotidine 20–40 mg): useful for nocturnal and mild reflux; ranitidine was withdrawn from many markets and dropped from NLEM 2022 after NDMA impurity concerns — famotidine is the successor.
- Misoprostol 200 µg qid: PGE1 analogue for NSAID-ulcer prophylaxis in high-risk patients; diarrhoea and abortion risk — absolutely contraindicated in pregnancy.
- Sucralfate 1 g qid: aluminium salt that coats the ulcer base, needs acid, minimal systemic absorption; separate from other drugs by 2 hours; it was deleted from NLEM 2022 as antacids and PPIs covered its role.
- Antacids: aluminium causes constipation, magnesium causes diarrhoea — combined products balance both; magnesium-containing antacids are avoided in renal failure (hypermagnesaemia), aluminium in renal failure (toxicity).
- Bleeding ulcer protocol: intravenous PPI bolus then infusion after endoscopic haemostasis reduces rebleeding — esomeprazole 80 mg bolus plus 8 mg/hour for 72 hours is the classic schedule.
A worked pathway from dyspepsia to eradication check
A 45-year-old presents with epigastric burning and a positive H. pylori stool antigen. Step one: test-and-treat applies under 60 without alarm features; above that age or with weight loss, anaemia or dysphagia, endoscopy comes first to exclude malignancy. Step two: choose the regimen with local resistance in mind — in most Indian cities, 14 days of bismuth quadruple therapy (PPI bid, bismuth subcitrate, tetracycline 500 mg qid, metronidazole 400 mg tid-qid) or concomitant four-drug therapy beats standard triple. Step three: counsel on metronidazole (avoid alcohol — disulfiram-like reaction) and bismuth (black stools, black tongue — harmless, alarming if unexplained). Step four: symptom relief need not wait; the PPI heals while antibiotics eradicate.
Step five, the one everybody forgets: confirm eradication with urea breath test or stool antigen at least four weeks after finishing antibiotics and 1–2 weeks off PPI — earlier testing yields false negatives because bacterial load and the acid environment are still recovering. If the breath test stays positive, salvage therapy with levofloxacin-based triple therapy follows, and a retreatment regimen never repeats clarithromycin.
Where students slip
Timing questions dominate: PPI before meals (not after), antibiotics for 14 days (not 7 in this era of resistance), eradication testing at 4 weeks off-antibiotic and off-PPI. The second trap pairs drugs with patients — misoprostol in a pregnant NSAID user is always the wrong option, and the abortifacient mechanism is the tested explanation. Third is the ranitidine story: stems referencing NDMA impurity, withdrawal and the NLEM 2022 deletion reward candidates who follow pharmacovigilance news; famotidine is the answer to "which H2 blocker now". Finally, corticosteroids alone are not ulcerogenic the way NSAIDs are — the classic pairing is NSAID with an H. pylori-positive stomach.
Frequently asked questions
When should a PPI be taken and why?
Thirty to sixty minutes before the first meal, because the inactive drug must accumulate in acid-activated parietal-cell canaliculi as meal-stimulated proton pumps are being inserted.
What is first-line H. pylori eradication therapy?
A 14-day regimen: PPI twice daily with amoxicillin 1 g and clarithromycin 500 mg twice daily — replaced by bismuth quadruple or concomitant therapy where clarithromycin resistance exceeds 15 per cent, as in much of India.
Why is misoprostol contraindicated in pregnancy?
It is a prostaglandin E1 analogue that contracts the uterus and induces abortion, so it is confined to NSAID-ulcer prophylaxis with contraception counselling.
How is H. pylori eradication confirmed?
By urea breath test or stool antigen at least four weeks after antibiotics and one to two weeks after stopping PPI therapy; earlier testing gives false negatives.
Which ulcer-prophylaxis drug suits a patient needing continued NSAIDs?
A proton pump inhibitor or misoprostol; for cardiovascular-risk patients on aspirin, adding a PPI (rather than switching agents) is the standard gastroprotection.