Gastric and duodenal ulcer - Treatment with medicines

The basis of modern treatment of ulcer disease is medication. It should be noted that there are no differences in the drug treatment of gastric ulcer and duodenal ulcer.

Before buying (and especially before taking) any drug, you should carefully read the instructions for its use, paying attention not only to the indications and dosage, but also to contraindications and possible side effects. If this drug is contraindicated for you, buy another drug after consulting with your doctor. Knowing the side effects will help you understand the appearance of some new sensations and treat them correctly.

There are several main groups of drugs used to treat peptic ulcer disease:

• antisecretory drugs,
• bismuth-containing preparations,
• antibiotics and antiprotozoal agents (from protozoa - protozoa),
• prokinetics (from kinetikos - setting in motion),
• antacid drugs.

Antisecretory drugs inhibit gastric secretion and reduce the aggression of gastric juice. The group of antisecretory drugs is heterogeneous, it includes proton pump inhibitors, H2-histamine receptor blockers, M1-anticholinergics.

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Proton pump inhibitors

• Omeprazole (syn.: zerocid, losek, omez) is prescribed at 20 mg 1 or 2 times a day.
• Pariet (syn.: rabeprazole) is prescribed at 20 mg 1 or 2 times a day.
• Esomeprazole (syn.: Nexium) is prescribed at 20 mg 1 or 2 times a day.

Proton pump inhibitors, compared to other antisecretory drugs, most strongly reduce gastric secretion and inhibit the formation of hydrochloric acid and the production of pepsin (the main gastric digestive enzyme). Omeprazole at a dose of 20 mg can reduce the daily formation of hydrochloric acid by 80%. In addition, against the background of the action of proton pump inhibitors, antibiotics more effectively suppress the vital activity of Helicobacter pylori. It is advisable to take proton pump inhibitors 40-60 minutes before meals.

H2-histamine receptor blockers

• Ranitidine (syn.: histac, zantac, zoran, ranigast, ranisan, rantak) is prescribed at 150 mg 2 times a day (after breakfast and at night) or 1 time - 300 mg at night.
• Famotidine (syn.: blokacid, gastrosidin, quamatel, ulfamid, ultseron, famonit, famosan) is prescribed at 20 mg 2 times a day (after breakfast and at night) or 1 time - 40 mg at night.

H2-histamine receptor blockers inhibit the production of hydrochloric acid and pepsin. Currently, ranitidine and famotidine are mainly prescribed from the group of H2-histamine receptor blockers for the treatment of peptic ulcer. Ranitidine at a dose of 300 mg can reduce the daily formation of hydrochloric acid by 60%. Famotidine is believed to act longer than ranitidine. Cimetidine is currently practically not used due to side effects (with prolonged use, it can cause a decrease in sexual potency in men). H2-histamine receptor blockers (like proton pump inhibitors) create a more favorable environment for the action of antibiotics on Helicobacter pylori; they are taken regardless of food intake (before, during and after meals), since the time of administration does not affect their effectiveness.

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M1-anticholinergics

Pirenzepine (syn.: gastrozepin, pyren) is usually prescribed at 50 mg 2 times a day before meals.

This drug reduces the secretion of hydrochloric acid and pepsin, reduces the tone of the gastric muscles. M1-anticholinergic platifillin as an independent treatment for peptic ulcer is currently not used.

Preparations containing bismuth

• Vikalin (1-2 tablets) is dissolved in 1/2 glass of water and taken after meals 3 times a day.
• Vikair is taken 1-2 tablets 3 times a day 1-1.5 hours after meals.
• Bismuth nitrate basic is taken 1 tablet 2 times a day after meals.
• De-nol (syn.: bismuth subcitrate) is prescribed either 4 times a day - 1 hour before breakfast, lunch, dinner and at night, or 2 times a day - in the morning and in the evening.

Bismuth-containing drugs inhibit the activity of Helicobacter pylori, form a film that protects the ulcer from the action of gastric juice, increase the formation of ulcer-protecting gastric mucus, improve blood supply to the mucous membrane and increase the resistance of the gastric mucosa to factors of gastric aggression. It is fundamentally important that bismuth preparations, inhibiting the activity of Helicobacter pylori, do not change the properties of gastric juice. Bismuth-containing drugs color feces black.

Ranitidine bismuth citrate is a complex agent (contains ranitidine and a bismuth preparation), has an astringent and antacid effect, and also suppresses the activity of Helicobacter pylori.

Sucralfate (Venter) is prescribed as an independent drug

The aluminum-containing antiulcer drug sucralfate (syn.: venter) covers the ulcer with a protective layer and prevents the destructive action of hydrochloric acid and pepsin. In addition, venter reduces the activity of pepsin and acts as a weak antacid.

Antibiotics and antiprotozoal drugs

• Amoxicillin is prescribed at 1000 mg 2 times a day (12-hour interval) half an hour before meals or 2 hours after meals.
• Clarithromycin (syn.: klacid) is prescribed at 500 mg 2 times a day (12-hour interval) during meals.
• Metronidazole (syn.: Trichopolum) is prescribed at 250 mg 4 times a day (or 500 mg 2 times a day). The drug should be taken at equal (6 or 12 hours) intervals after meals.
• Tetracycline is prescribed at 500 mg 4 times a day after meals.
• Tinidazole (syn.: fazizhin) is taken 500 mg 2 times a day (12 hours apart) after meals.

Antibiotics and antiprotozoal drugs are prescribed to suppress the activity of Helicobacter pylori.

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Prokinetics

• Coordinax (syn.: cisapride) is prescribed at 5-10 mg 3-4 times a day before meals.
• Motilium (syn.: domperidone) is prescribed 10 mg 3-4 times a day 15-30 minutes before meals and at night.
• Cerucal (syn.: metoclopramide) is prescribed at 10 mg 3 times a day 30 minutes before meals.

Prokinetics, improving the motor function of the stomach, eliminate nausea and vomiting, are indicated for heartburn, a feeling of heaviness and fullness in the stomach, early satiety, and eliminate discomfort. These drugs are contraindicated in stenosis (narrowing) of the pylorus - the outlet of the stomach. Prokinetics do not have an antiulcer effect and are not prescribed as an independent remedy for the treatment of peptic ulcer disease.

Antacid drugs

• Almagel is prescribed 1 teaspoon 4 times a day.
• Almagel A is prescribed 1-3 measuring spoons 3-4 times a day.
• Almagel is prescribed 1 sachet or 2 measuring spoons 4 times a day 1 hour after meals and in the evening before bed.
• Gastal is prescribed 4-6 times a day 1 hour after meals.
• Gelusil (gelusil varnish) is available as a suspension, tablets, and powder. Gelusil is prescribed 3-6 times a day 1-2 hours after meals and 1 hour before bedtime. The suspension is not dissolved, the powder is dissolved in a small amount of water, the tablets are sucked or chewed.
• Maalox is prescribed 1-2 sachets (or 1-2 tablets) 4 times a day 1-1.5 hours after meals.
• Phosphalugel is prescribed 1-2 sachets 4 times a day.

Antacids are prescribed symptomatically, they quickly eliminate heartburn and pain (or reduce their intensity) due to the acid-neutralizing effect, and also have an astringent and adsorbing effect. Antacids can be successfully used "on demand" as an emergency means of eliminating heartburn. These drugs should not be taken for more than 2 weeks in a row due to the possibility of developing side effects. Antacids do not have an antiulcer effect and are not used as an independent means for the treatment of peptic ulcer disease.

In addition to the above-mentioned main groups of drugs, some painkillers (for example, baralgin, ketorol), antispasmodics (for example, no-shpa, droveryne), and drugs that improve the nutrition of the gastric and intestinal mucosa (for example, biogenic drugs such as solcoseryl, actovegin, B vitamins) can be used for peptic ulcer disease. Gastroenterologists (or therapists) prescribe these drugs according to certain schemes. Treatment schemes are developed and periodically updated by leading gastroenterologists in the form of standards. Doctors of medical institutions are obliged to be guided by these standards in their daily practice.

Drug treatment of peptic ulcer disease is based on whether Helicobacter pylori is detected in the patient's gastric mucosa or not. If they are detected, they speak of peptic ulcer disease associated (from association - to connect) with Helicobacter pylori, if they are absent - of peptic ulcer disease not associated with Helicobacter pylori.

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Treatment of peptic ulcer disease not associated with helicobacter pylori

Before the introduction of proton pump inhibitors (omeprazole, pariet, esomeprazole, etc.), the main means of treating peptic ulcer disease were H2-histamine receptor blockers (ranitidine, famotidine, etc.). Even earlier (before the invention of H2-histamine receptor blockers), the basis for treating peptic ulcer disease were bismuth preparations (vicalin, bismuth subnitrate).

Basic, primary treatment of peptic ulcer disease is carried out with antisecretory drugs, bismuth preparations or sucralfate. The duration of treatment with antiulcer antisecretory drugs is at least 4-6 weeks for duodenal ulcer and at least 6-8 weeks for gastric ulcer. Antacids and prokinetics are prescribed in addition to basic therapy as symptomatic means to eliminate heartburn and pain.

Use of H2-histamine receptor blockers

• Ranitidine is taken at 300 mg per day once in the evening (at 7-8 p.m.) or 150 mg 2 times a day. Additionally, antacid drugs (maalox, phosphalugel, gastal, etc.) or prokinetics (motilium, etc.) can be prescribed as symptomatic agents.
• Famotidine is taken at 40 mg per day once in the evening (at 7-8 p.m.) or 20 mg 2 times a day. Additionally - an antacid drug (Gastal, etc.) or a prokinetic (Motilium, etc.).

Use of proton pump inhibitors

• Omeprazole (syn.: omez) 20 mg per dose.
• Pariet (syn.: rabeprazole) 20 mg per dose.
• Esomeprazole (syn.: Nexium) 20 mg per dose.

The combination drug ranitidine bismuth citrate can also be prescribed as a basic treatment for peptic ulcer disease. The drug is prescribed at 400 mg 2 times a day (for duodenal ulcers, take for at least 4 weeks, for gastric ulcers - 8 weeks).

De-nol, a bismuth preparation, is taken according to two possible regimens:

• 240 mg 2 times a day 30 minutes before meals or 2 hours after meals;
• 120 mg 4 times a day - before breakfast, lunch, dinner and before bed.

Sucralfate (syn.: venter) for the treatment of peptic ulcer is prescribed 1 g 4 times a day - 1 g 30 minutes or 1 hour before meals (before breakfast, lunch, dinner) and in the evening 2 hours after meals or before bedtime; the course of treatment is 4 weeks, and then, if necessary, continue taking the drug 2 g per day for 8 weeks.

The daily dose, duration of treatment, and the need to include an antacid (Almagel, etc.) or prokinetic (Motilium, etc.) in the treatment regimen are determined by the doctor.

The combined use of basic antiulcer drugs and antacids (almagel, maalox, rutacid, etc.), which can quickly neutralize excess hydrochloric acid in the stomach cavity, quickly eliminates heartburn and pain. At the same time, it is necessary to know that antacid drugs slow down the absorption of other drugs, so they should be taken separately: the interval between taking an antacid and another drug should be at least 2 hours.

Using one or another scheme, it is quite possible to achieve good treatment results, but the art of the doctor is to prescribe individual therapy to each patient to achieve the best results with the least losses (to achieve rapid and stable remission with a minimum of side effects and minimum financial costs).

Proton pump inhibitors (omeprazole, etc.) are currently the most powerful means of suppressing factors of gastric aggression. At the same time, it has been established that it is not always necessary to reduce the level of hydrochloric acid and pepsin in the stomach as much as possible. In many cases, it is sufficient to use ranitidine or famotidine (they are cheaper than omeprazole and pariet). If necessary, the doctor can increase the dose of ranitidine or famotidine for 3-4 days, which accelerates the healing of the ulcer defect, but it is impossible to change the treatment regimen on your own due to the increased risk of side effects. It is possible to use omeprazole in combination with ranitidine or famotidine, but only an experienced specialist can prescribe such a regimen.

When prescribing drug therapy, the size of the ulcer defect is important: if the size of the duodenal ulcer exceeds 9 mm, and the size of the gastric ulcer exceeds 7 mm, then it is better to use stronger drugs (omeprazole, etc.).

A good effect can also be achieved by using bismuth preparations or by taking sucralfate. De-nol (colloidal bismuth subcitrate) can be prescribed according to two schemes: either 240 mg twice a day (12-hour interval) 30 minutes before breakfast and dinner; or 120 mg four times a day - before breakfast, lunch, dinner and before bed.

Sucralfate (Venter) is taken 4 times a day: 1 g before breakfast, lunch, dinner and at night. Treatment with de-nol or venter is advisable for small, uncomplicated ulcers, with mild symptoms (primarily pain and heartburn). At the same time, for more severe symptoms - pain, heartburn - or larger ulcer defects, de-nol and venter are recommended to be combined with ranitidine (or famotidine).

When treating elderly patients, age-related disorders of blood circulation in the stomach walls are taken into account. To improve blood circulation in small blood vessels of the stomach, colloidal bismuth subcitrate (de-nol) is indicated among antiulcer drugs. Additionally, it is advisable for elderly people to take actovegin, which improves metabolic processes in the body's tissues, and solcoseryl, which has a wound-healing effect.

Treatment of peptic ulcer disease associated with helicobacter pylori

In gastric ulcers, Helicobacter pylori is detected in 80-85% of cases, and in duodenal ulcers - in 90-95% of cases. When the patient's gastric mucosa is infected with Helicobacter pylori, a course of eradication therapy is carried out - this is the name of the treatment to free the mucosa from Helicobacter. Eradication therapy should be carried out regardless of the phase of peptic ulcer disease - exacerbation or remission, but in practice, outside of an exacerbation of peptic ulcer disease, examination of the gastric mucosa for the presence of Helicobacter pylori is most often not carried out.

The indication for eradication therapy (in the presence of H. pylori) is gastric ulcer or duodenal ulcer in the acute or remission phase, including complicated peptic ulcer.

Currently, in accordance with the decisions of the Maastricht-3 Consensus Meeting (2005), a standardized combination of three drugs is recommended as first-line therapy - the most effective eradication regimen.

Proton pump inhibitor at a double dose (rabeprazole - 20 mg 2 times a day, or omeprazole at a dose of 20 mg 2 times a day, or esomeprazole at a dose of 40 mg 2 times a day, or lansoprazole - 30 mg 2 times a day, or pantoprazole - 40 mg 2 times a day).

• Clarithromycin - 500 mg 2 times a day.
• Amoxicillin - 1000 mg 2 times a day.

This regimen is prescribed only if the resistance rates of H. pylori strains to clarithromycin in a given region do not exceed 20%. The effectiveness of a 14-day eradication course is 9-12% higher than a 7-day course.

In case of uncomplicated duodenal ulcer, there is no need to continue antisecretory therapy after the eradication course. In case of exacerbation of gastric ulcer, as well as in case of exacerbation of duodenal ulcer occurring against the background of concomitant diseases or with complications, it is recommended to continue antisecretory therapy using one of the antisecretory drugs (more effective proton pump inhibitors or H2-histamine receptor blockers) for 2-5 weeks for effective ulcer healing.

The eradication therapy protocol requires mandatory monitoring of its effectiveness, which is carried out 4-6 weeks after the end of taking antibacterial drugs and proton pump inhibitors. The optimal method for diagnosing H. pylori infection at this stage is a breath test, but if it is not available, other diagnostic methods can be used.

If first-line therapy is ineffective, it is recommended to prescribe second-line therapy (quadruple therapy), including:

Proton pump inhibitor (omeprazole, or lansoprazole, or rabeprazole, or esomeprazole, or pantoprazole) at standard dose 2 times daily;

• bismuth subsalicylate/subcitrate - 120 mg 4 times a day;
• tetracycline - 500 mg 4 times a day;
• metronidazole (500 mg 3 times daily) or furazolidone (50-150 mg 4 times daily) for at least 7 days.

In addition, a combination of amoxicillin (750 mg 4 times daily) with proton pump inhibitors, rifabutin (300 mg/day), or levofloxacin (500 mg/day) may be prescribed as backup eradication regimens.

In the absence of H. pylori, patients with gastric ulcer are prescribed basic therapy with proton pump inhibitors, which are preferable to histamine H2-receptor blockers _. Various representatives of the proton pump blocker group are equally effective. The following drugs are used:

• rabeprazole at a dose of 20 mg/day;
• omeprazole at a dose of 20-40 mg/day;
• esomeprazole at a dose of 40 mg/day;
• lansoprazole at a dose of 30-60 mg/day;
• pantoprazole at a dose of 40 mg/day.

The duration of the course of treatment is usually 2-4 weeks, if necessary - 8 weeks (until the symptoms disappear and the ulcer heals).

Lansoprazole (EPICUR®)

Lansoprazole is one of the most widely known and used proton pump inhibitors with a powerful antacid effect in the world. Trust in this drug is based on numerous and reliable data on pharmacodynamics and pharmacokinetics, on a well-studied antisecretory effect. In all comparative studies of omeprazole, pantoprazole, lansoprazole and rabeprazole (by intragastric pH and time of pH> 4), the best indicators are for rabeprazole and lansoprazole compared to pantoprazole and omeprazole. The drug is distinguished by an early onset of antisecretory effect. Antihelicobacter activity has been proven. Due to good tolerability and safety, lansoprazole can be recommended for long-term use.

Indications, method of administration and dosage: For gastric ulcer and erosive-ulcerative esophagitis - 30 mg/day for 4-8 weeks; if necessary - 60 mg/day. For reflux esophagitis - 30 mg/day for 4 weeks. Non-ulcer dyspepsia: 15-30 mg/day for 2-4 weeks. For Hp eradication - in accordance with these clinical guidelines.

Contraindications: standard for PPIs.

Packaging: EPICUR® - capsules of 30 mg No. 14 contain microspheres with an acid-resistant coating that prevents destruction in the stomach. EPICUR® belongs to the category of affordable drugs.

_{Histamine H2} receptor blockers are less effective than proton pump inhibitors. The following drugs are prescribed:

• ranitidine at a dose of 150 mg 2 times a day or 300 mg at night;
• famotidine at a dose of 20 mg 2 times a day or 40 mg at night.

Antacid drugs (aluminum-magnesium antacids or aluminum-magnesium with the addition of calcium alginate 1.5-2 hours after meals or on demand, or aluminum-magnesium antacid with the addition of simethicone and biologically active substances (powder of naked licorice roots), which enhance the antacid effect and mucus formation) are used additionally as symptomatic agents.

To prevent exacerbations (especially if the patient has a high risk of ulcer recurrence: for example, if there is a need for constant use of NSAIDs), maintenance use of antisecretory drugs in half daily doses over a long period of time (1-2 years) is indicated.