Stomach and duodenal ulcer: drug treatment

The basis of modern treatment of peptic ulcer is medications. It should be noted that there is no difference in the drug treatment of peptic ulcer of the stomach and duodenum.

Before buying (and especially before taking) any drug 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 to you, buy, after consulting with your doctor, another medicine. 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,
• preparations containing bismuth,
• antibiotics and antiprotozoals (from protozoa - protozoa),
• prokinetics (from kinetikos - propelling),
• antacid preparations.

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

[1], [2], [3], [4], [5], [6], [7],

Proton pump inhibitors

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

Proton pump inhibitors in comparison with 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 in a dose of 20 mg can reduce the daily production of hydrochloric acid by 80%. In addition, against the background of the action of proton pump inhibitors, antibiotics more effectively inhibit the vital activity of Helicobacter pylori. Proton pump inhibitors should be taken 40-60 minutes before meals.

Blockers of H2-histamine-receptors

• Ranitidine (syn: histak, zantak, zoran, ranigast, ranisan, rantak) is prescribed for 150 mg 2 times a day (after breakfast and at night) or 1 time 300 mg at night.
• Famotidine (syn: blockade, gastrosidin, kvamatel, ulfamid, ulceron, famonit, famosan) is prescribed for 20 mg 2 times a day (after breakfast and at night) or 1 time - 40 mg at night.

The blockers of H2-histamine-receptors inhibit the production of hydrochloric acid and pepsin. Currently, for treatment of peptic ulcer from the group of H2-histamine-blocker blockers, predominantly ranitidine and famotidine are prescribed. Ranitidine in a dose of 300 mg can reduce the daily production of hydrochloric acid by 60%. It is believed that famotidine acts longer than ranitidine. Tsimitidin is currently almost not used because of side effects (with prolonged use it can cause a decrease in sexual potency in men). The H2-histamine-receptor blockers (as well as the 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 reception does not affect their effectiveness.

[8], [9], [10], [11], [12], [13]

M1 anticholinergics

Pirenzepine (syn: gastrotsepin, pyrene) is usually administered at 50 mg 2 times daily before meals.

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

Preparations containing bismuth

• Vikalin (1-2 tablets) is dissolved in 1/2 cup of water and taken after meals 3 times a day.
• Vicair take 1-2 tablets 3 times a day 1-1.5 hours after meals.
• Bismuth nitrate basic take 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 vital activity of Helicobacter pylori, form a film that protects the ulcer from the action of gastric juice, increase the formation of the gastric ulcer protecting the ulcer, improve the blood supply to the mucosa and increase the stability of the gastric mucosa to factors of gastric aggression. It is of fundamental importance that the preparations of bismuth, suppressing the activity of Helicobacter pylori, do not change the properties of gastric juice. Bismuth-containing preparations stain the feces in black.

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

Sucralfate (Venter) is designated as an independent agent

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

Antibiotics and antiprotozoals

• Amoxicillin is prescribed 1000 mg twice a day (12 hours interval) half an hour before meals or 2 hours after meals.
• Clarithromycin (syn: klatsid) is prescribed for 500 mg 2 times a day (interval 12 hours) with meals.
• Metronidazole (syn: trihopol) is prescribed for 250 mg 4 times a day (or 500 mg 2 times a day). The drug should be taken at regular intervals (6 or 12 hours) after meals.
• Tetracycline is prescribed 500 mg 4 times daily after meals.
• Tinidazole (syn: fazizhin) take 500 mg 2 times a day (interval 12 hours) after meals.

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

[14], [15], [16], [17]

Prokinetics

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

Prokinetics, improving the motor function of the stomach, eliminate nausea and vomiting, are shown with heartburn of gravity and overflow in the stomach, early satiety, eliminate discomfort. These drugs are contraindicated in the stenosis (narrowing) of the gatekeeper - the outlet of the stomach. Prokinetics have no anti-ulcerative effect and are not prescribed as an independent agent for the treatment of peptic ulcer.

Antacid preparations

• Almagel is prescribed 1 teaspoonful 4 times a day.
• Almagel A appoint 1-3 doses of 3-4 times a day.
• Almagel appoint 1 packet or 2 metered spoons 4 times a day 1 hour after meals and in the evening before bedtime.
• Gastal is prescribed 4-6 times a day 1 hour after meals.
• Gelusil (gelucil varnish) is available in the form of a suspension, tablets, 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 resorbed or chewed.
• Maaloks appoint 1-2 packets (or 1-2 tablets) 4 times a day 1-1.5 hours after meals.
• Phosphalugel is prescribed for 1-2 packets 4 times a day.

Antacids are prescribed symptomatically, they quickly eliminate heartburn and pain (or reduce their intensity) due to the neutralizing action of the acid, and also have astringent and adsorbing action. Antacids can be successfully applied "on demand" as a means of emergency relief of heartburn. More than 2 weeks in a row, these drugs should not be taken because of the potential for side effects. Antacids do not possess antacids and are not used as an independent agent for the treatment of peptic ulcer.

In addition to the aforementioned main groups of drugs, peptic ulcer can use some analgesics (eg, baralgin, ketorol), antispasmodics (eg, no-shpa, droverin), as well as drugs that improve the nutrition of the mucous membrane of the stomach and intestines (for example, such biogenic drugs like solcoseryl, actovegin, B vitamins). These drugs are prescribed by gastroenterologists (or therapists) according to certain schemes. The treatment regimens are developed and periodically refined by leading experts-gastroenterologists in the form of standards. Doctors of medical institutions are obliged to be guided by these standards in daily practice.

Medicamental treatment of peptic ulcer is built depending on whether they are found in the gastric mucosa of a patient with Helicobacter pylori or not. When they are identified, they speak of a peptic ulcer associated with Helicobacter pylori, from their association with a Helicobacter pylori ulcer disease .

[18], [19], [20], [21], [22], [23]

Treatment of peptic ulcer, not associated with helicobacter pylori

Prior to the introduction into practice of inhibitors of the proton pump (omeprazole, pariet, esomeprazole, etc.), the main agents for treating peptic ulcer were H2-histamine-receptor blockers (ranitidine, famotidine, etc.). Even earlier (before the invention of H2-histamine-receptor blockers), the basis of treatment of peptic ulcer was bismuth preparations (vocalin, bismuth subnitrate).

Basis, the main treatment of peptic ulcer is carried out with antisecretory drugs, bismuth preparations or sucralfate. The duration of treatment with antiulcer antisecretory drugs is at least 4-6 weeks with duodenal ulcer and at least 6-8 weeks with gastric ulcer. Antacid preparations and prokinetics are prescribed in addition to basic therapy as symptomatic agents for the elimination of heartburn and pain.

The use of H2-histamine-receptor blockers

• Ranitidine is taken 300 mg per day once in the evening (at 19-20 hours) or 150 mg 2 times a day. Additionally, antacid preparations (maalox, fosfalugel, gastal, etc.) or prokinetics (motilium, etc.) may be prescribed as symptomatic agents.
• Famotidine is taken at 40 mg per day once in the evening (at 19-20 hours) or 20 mg twice a day. In addition - antatsidny drug (Gastal, etc.) or prokinetics (motilium, etc.).

Use of proton pump inhibitors

• Omeprazole (syn: omez) for 20 mg per reception.
• Pariet (syn: rabeprazole) of 20 mg per reception.
• Esomeprazole (syn: nexium) of 20 mg per reception.

As a basic treatment for peptic ulcer, a complex drug ranitidine bismuth citrate can also be prescribed. The medicine prescribes 400 mg twice a day (with ulcer of the duodenum, taking at least 4 weeks, with a stomach ulcer - 8 weeks).

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

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

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

The daily dose, duration of treatment, the need for inclusion in the treatment of antacids (almagel, etc.) or prokinetics (motilium, etc.) is determined by the doctor.

The combined use of basic antiulcer drugs and antacids (almagel, maalox, ruticide, etc.), capable of quickly neutralizing excess hydrochloric acid in the stomach cavity, quickly eliminates heartburn and pain. At the same time, it is necessary to know that antacid preparations slow 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 this or that scheme, it is quite possible to achieve good results of treatment, but the art of the doctor is to appoint individual therapy for each patient to achieve the best results with the least loss (to achieve quick and stable remission with a minimum of side effects and a minimum of financial costs).

Inhibitors of the proton pump (omeprazole, etc.) are today the most powerful means of suppressing the factors of gastric aggression. At the same time, it has been established that the level of hydrochloric acid and pepsin in the stomach should not be reduced as much as possible. In many cases, it is sufficient to use ranitidine or famotidine (they are cheaper than omeprazole and parieta). If necessary, the doctor can increase the dose of ranitidine or famotidine by 3-4 days, which accelerates the healing of the ulcerative defect, but it is impossible to change the scheme of treatment independently because of the increased risk of side effects. Perhaps the combined use of omeprazole with ranitidine or famotidine, but this scheme can only appoint an experienced specialist.

When the medication is prescribed, the size of the ulcerative defect is important: if the dimensions of the duodenal ulcer exceed 9 mm, and the size of the stomach ulcer exceeds 7 mm, then it is better to use stronger medications (omeprazole, etc.).

A good effect can also be obtained with the use of bismuth preparations or with the administration of sucralfate. De-nol (colloidal bismuth sub-citrate) can be prescribed according to two schemes: or 2 times a day for 240 mg (interval 12 hours) 30 minutes before breakfast and dinner; or 4 times a day for 120 mg - before breakfast, lunch, dinner and at bedtime.

Sucralfate (Venter) is taken 4 times a day: 1 g before breakfast, lunch, dinner and overnight. Treatment with de-nol or venema is advisable to carry out with small, uncomplicated ulcers, with mildly expressed symptoms (especially pain and heartburn). At the same time, with more severe symptoms - pain, heartburn - or more significant dimensions of the ulcer defect de-nol and the ventilator is recommended to combine with ranitidine (or famotidine).

In the treatment of elderly patients, age-related violations of blood circulation in the walls of the stomach are taken into account. To improve blood circulation in small blood vessels of the stomach from antiulcer drugs, the reception of colloidal bismuth subcitrate (de-nol) is shown. In addition, elderly people should take actovegin, which improves metabolic processes in the tissues of the body, and solcoseryl, which has a wound-healing effect.

Treatment of peptic ulcer associated with helicobacter pylori

With the stomach ulcer Helicobacter pylori are found in 80-85% of cases, and with duodenal ulcer - in 90-95% of cases. When infection of the gastric mucosa of a patient with Helicobacter pylori, a course of eradication therapy is carried out - the so-called treatment for the release of the mucosa from helicobacteria. Carrying out eradication therapy should be carried out regardless of the phase of peptic ulcer disease - exacerbation or remission, however, in practice, exacerbation of peptic ulcer examination of the gastric mucosa for the presence of Helicobacter pylori is most often not performed.

Indication for carrying out eradication therapy (in the presence of H. Pylori) is peptic ulcer of the stomach or duodenum in the phase of exacerbation or remission, including a complicated ulcer disease.

Currently, in accordance with the decisions of the conciliation meeting Maastricht-3 (2005), as a first-line therapy, a standardized combination of three medicines is recommended - the most effective eradication scheme.

The proton pump inhibitor in a double dose (rabeprazole 20 mg twice a day, or omeprazole 20 mg twice daily, or esomeprazole 40 mg twice a day, or lansoprazole 30 mg twice a day, or pantoprazole - 40 mg twice a day).

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

This scheme is appointed only if the resistance of H. Pylori strains to clarithromycin in this region does not exceed 20%. The effectiveness of the 14-day eradication course is 9-12% higher than the 7-day rate.

With an uncomplicated peptic ulcer of the duodenum, there is no need to continue antisecretory therapy after the eradication course. In case of exacerbation of peptic ulcer of the stomach, as well as during exacerbation of duodenal ulcers taking place against the background of concomitant diseases or with complications of duodenal ulcer, it is recommended to continue antisecretory therapy using one of the antisecretory drugs (more effective proton pump inhibitors or histamine H2 receptor blockers) for 2-5 ned for effective healing of the ulcer.

The protocol of eradication therapy presupposes mandatory control of its effectiveness, which is carried out 4-6 weeks after the end of the intake of antibacterial drugs and proton pump inhibitors. The optimal method of diagnosing H. Pylori infection at this stage is a respiratory test, but in its absence other diagnostic methods can be used.

If the first-line therapy is ineffective, the appointment of second-line therapy (quadratherapy) is recommended, which includes:

A proton pump inhibitor (omeprazole, or lansoprazole, or rabeprazole, or esomeprazole, or pantoprazole) in a standard dose 2 times a day;

• 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 blockers, rifabutin (300 mg / day) or levofloxacin (500 mg / day) may be prescribed as a reserve eradication scheme.

In the absence of H. Pylori, peptic ulcer patients are prescribed basal therapy with proton pump inhibitors, which are preferable to histamine H ₂ -receptor blockers . Different representatives of the group of proton pump blockers are equally effective. The following drugs are used:

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

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

Lansoprazole (EPICUR®)

In the world, lansoprazole is one of the most widely known and used inhibitors of a proton pump with a powerful anti-acid effect. The credibility of this drug is based on numerous and reliable data on pharmacodynamics and pharmacokinetics, on well-studied antisecretory action. In all comparative studies of omeprazole, pantoprazole, lansoprazole, and rabeprazole (in terms of intragastric pH and pH> 4), rabeprazole and lansoprazole are better than pantoprazole and omeprazole. The drug distinguishes the early onset of antisecretory effect. Proved anti-Helicobacter pylori activity. Due to the good tolerability and safety, lansoprazole can be recommended for long-term use.

Indication, mode of administration and dose: With peptic ulcer and erosive-ulcerative esophagitis - 30 mg / day for 4-8 weeks; if necessary, 60 mg / day. With reflux-esophagitis - 30 mg / day for 4 weeks. Non-ulcer dyspepsia: 15-30 mg / day for 2-4 weeks. For eradication of Hp - in accordance with these clinical recommendations.

Contraindications: standard for PPI.

Packing: EPICUR® capsules of 30 mg No. 14 contain microspheres that have an acid-fast coating that prevents destruction in the stomach. EPICUR® is classified as affordable.

H ₂ -receptor blockers of histamine are less effective than proton pump inhibitors. Assign the following drugs:

• ranitidine in a dose of 150 mg twice a day or 300 mg per night;
• famotidine in a dose of 20 mg twice a day or 40 mg per night.

Antacid preparations (aluminum-magnesium antacids or aluminum-magnesium with the addition of calcium alginate 1.5-2 h after meal or on demand, or aluminum-magnesium antacid with the addition of simethicone and BAS (powder of licorice roots naked), enhancing the antacid effect and mucus ) are used additionally as symptomatic agents.

For the prevention of exacerbations (especially if the patient has a high risk of recurrence of ulcers: for example, if there is a need for continuous intake of NSAIDs), supportive administration of antisecretory medications at half daily doses for a long time (1-2 years) is indicated.