Drugs In Practice

Drugs for GERD and Peptic Ulcer Disease gastric pH varies from drug to drug (see Table 1). 8 PPIs should be given twice daily (30-60 minutes before breakfast and dinner) for treatment of H. pylori infection. Dexlansoprazole can be given without regard to meals. Some experts recommend using high PPI doses (e.g., omeprazole 40 mg bid) for H. pylori eradication, especially in patients who are CYP2C19 ultra-rapid metabolizers. 29

Treatment Failure

Testing for eradication of H. pylori should be performed at least 4 weeks after completion of therapy. Patients who are still infected should be treated with a different regimen. Bismuth quadruple therapy can be used in patients who initially received a regimen containing clarithromycin. Those who were initially treated with bismuth quadruple therapy can receive rifabutin triple therapy.

Other Drugs

Sucralfate, an aluminum hydroxide complex of sucrose thought to act locally to protect ulcers from exposure to pepsin and gastric acid, has been used to heal peptic ulcers and as maintenance treatment to prevent recurrence. It may not be effective in relieving ulcer pain, must be taken multiple times per day, and can reduce the absorption of drugs taken concomitantly.

Misoprostol, a prostaglandin E1 analog, can prevent and heal gastroduodenal ulcers in patients taking NSAIDs chronically, but it requires multiple daily doses and is not well tolerated.

Vonoprazan, a potassium-competitive acid blocker that has not been approved by the FDA to date, but has been available in Japan since 2014 for treatment of gastric and duodenal ulcers and eradication of H. pylori . It is more rapidly absorbed, achieves a higher intragastric pH, and has a substantially longer duration of action (half-life 7.7 hours) than conventional PPIs.30 It appears to be more effective than conventional PPIs in eradicating H. pylori , with similar adverse effects. 31

Adverse Effects

The most common adverse effects associated with use of antibacterial drugs for treatment of H. pylori are diarrhea, nausea, vomiting, anorexia, and abdominal pain.

Bismuth subsalicylate can temporarily turn the tongue and stool black and can cause tinnitus. Metronidazole frequently causes a metallic taste and might cause a disulfiram-like reaction to alcohol; neurologic adverse effects, including seizures and neuropathy, have also been reported, particularly at high doses. Tetracyclines can cause GI adverse effects, vaginal candidiasis, photosensitivity, intracranial hypertension, and hyperpigmentation. Use of tetracyclines during tooth development (second and third trimesters of pregnancy, children ≤8 years old) can result in permanent discoloration of teeth. Because of their adverse effects on tooth and bone development,