Treatment for peptic ulcer is dependent on the underlying cause of the ulcer. These include making lifestyle changes (e.g. alcohol/tobacco cessation, limiting NSAID use), medications, or surgical procedures.

Ulcer medications include:

1) Antibiotics – for elimination of H.pylori bacteria

If H. pylori infection is detected in the digestive tract, a combination of antibiotics may be recommended by the doctor to eliminate the bacteria. These antibiotics may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline (Tetracycline HCL) and levofloxacin (Levaquin). The choice of antibiotics depends on the location of the infection and the person’s antibiotic resistance rate. Antibiotics are likely prescribed for one to two weeks along with medications such as proton-pump inhibitor (PPI) to reduce gastric acid production.

Drawback of antibiotics:
Minor side effects such as diarrhoea or stomach upset may be experienced from antibiotic treatment. Further medical attention is required if serious discomfort continues and does not improve over time.

2) PPIs – block gastric acid production and support healing

If H. pylori infection is not detected in peptic ulcer diagnosis, proton pump inhibitors (PPIs) may be prescribed for up to eight weeks to reduce gastric acid production and promote natural healing of the ulcer. PPIs reduce gastric acid by blocking the action of gastric acid-producing cells. Since gastric acid is a prerequisite for the formation of most ulcers, the ulcers would be able to heal if not a large amount of acid is present. PPIs are commonly prescribed for peptic ulcers, acid reflux (GERD), dyspepsia (indigestion) and peptic oesophagitis (severe GERD with damage to the esophageal mucosa). PPIs include prescription and over-the-counter drugs like omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix) and are often used long-term for acid suppression and symptom relief.

Video on the acid-reducing mechanism of PPIs

Drawback of PPIs:
PPIs are popular options to help patients address gastric acid-related symptoms such as acid reflux and heartburn. Nonetheless, studies have associated these seemingly ‘harmless’ drugs to a number of significant medical problems.

i) Impaired digestion and nutrient absorption

PPIs reduce gastric acid in the stomach, which can hinder proper food digestion and absorption in the small intestine, leading to compromised nutrient benefits from food.

ii) Infection

Gastric acid is vital for defense against harmful bacteria in the stomach. PPI users whose gastric acid production is reduced by the drugs are vulnerable to infections like Clostridium difficile.

Additionally, PPIs inhibit the body’s proton pump that produces hydrogen for gastric acid. Upon completion of treatment and PPI withdrawn, many could not initiate the making of hydrogen for up to 3 weeks. During this low gastric acid period, there is an increased risk of H. pylori re-infection.

iii) Rebound acid hypersecretion and drug dependency

Withdrawal from PPI treatment can cause rebound acid hypersecretion, where acid production is a clinically significant increase to pre-treatment levels. This may lead to new symptoms like acid regurgitation, heartburn, and indigestion in some people who had no history of acid-related symptoms.

Rebound acid hypersecretion is speculated to be caused by excessive production of gastrin, a gastric acid-stimulating hormone, which is not apparent during PPI treatment but appears after the drug is stopped. This can result in a return of symptoms and long-term dependency on the medication for some patients. PPIs do not address the underlying cause of gastric symptoms.

iv) Increased risk of dementia

A recent study has revealed a link between PPIs and an increased risk of dementia in older patients. 40% of subjects aged 75 years and older who did not have dementia at the start of the studies were diagnosed with dementia, with 59% of them diagnosed with at least two different types of dementia (Gomm W et al., 2016).

This data is also in line with animal testing in which the use of PPIs has increased the levels of amyloid β (the hallmark brain protein for dementia) in the brains of mice. Avoidance of PPIs drug may hinder the development of dementia.

v) Increased risk of kidney disease

The use of PPIs has been associated to an increased risk of chronic kidney disease (CKD), CKD progression, and end-stage renal disease (ESRD). Analysis also revealed that the longer the duration of PPIs use, the greater the risk of renal outcomes (Xie Y et al., 2016). Another study also reported that those who took PPIs are associated with a significant 35% increase in CKD risk, compared to those who had never taken PPIs.

vi) Increased risk of heart attack

Prolonged use of PPIs has been linked to a slight elevated risk of heart attack (Shah NH et al., 2015). Researchers found that PPI users were 16 – 21% more likely to experience a heart attack, compared to those with chronic acid reflux but were not taking the drugs. Another study suggests that PPIs can disrupt normal blood vessel function, which could elevate the risk of heart attacks.

vii) Increased risk of bone fracture

Long-term PPI treatment has been associated with an increased occurrence of bone fracture (Ito T & Jensen RT, 2010). Further investigations are required to examine the possible effects of chronic acid suppression by PPIs on the absorption of key vitamins and nutrients.

ix) Increased risk of pneumonia

PPIs have been associated with an increased risk of pneumonia (Herzig SJ et al. 2009).

3) H2 blockers – block gastric acid production

Acid blockers, also known as histamine (H2) blockers, obstruct the chemical pathways that allow histamine to trigger the parietal cells of the stomach (that produce gastric acid), thereby reducing the amount of gastric acid. H2 blockers are commonly prescribed to soothe symptoms of acid reflux, relieve ulcer pain and promote healing. Prescribed or over-the-counter H2 blockers include ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).

Drawback of H2 blockers:
Long-term acid suppression by H2 blockers may lead to cancerous changes in the stomach if H. pylori infection is not treated. Tachyphylaxis, a fast declining response to successive doses of H2 blockers has been observed, suggesting that pharmacologic tolerance can reduce the long-term effectiveness of these medications. In addition, H2 blockers are associated with an increased risk for pneumonia. If the root cause of symptoms is not treated, ulcer complications such as perforation, bleeding and others may develop.

4) Antacids – neutralise gastric acid

Antacids neutralise existing gastric acid and this can provide rapid pain relief. This type of medication does not heal the ulcer and is only a temporary solution to a long-term problem. Many brands of antacids are available and can be purchased without a prescription. Some of the commonly used antacid chemical combinations are aluminium hydroxide, magnesium carbonate and magnesium trisilicate.

Drawback of antacids:
Long-term use of antacids is associated with some health problems such as poor digestion and decreased absorption of nutrients such as vitamin C, iron, calcium, magnesium, zinc, as well as increased risk of gastrointestinal infections. Antacids have also been associated with different side effects, depending on the main ingredients.

5) Medications that protect the linings of stomach and small intestine

Medications known as cytoprotective agents may be prescribed to help protect the tissues that line stomach and small intestine. Among the prescribed medications are sucralfate (Carafate) and misoprostol (Cytotec).

Drawback of cytoprotective agents:
The use of sucralfate and misoprostol medications may cause side effects such as dizziness, headache, diarrhoea and nausea.