Managing peptic ulcer disease in adults

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http://pathways.nice.org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-
disease
Pathway last updated: 13 December 2016

This document contains a single pathway diagram and uses numbering to link the
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 Managing peptic ulcer disease in adults NICE Pathways

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1 Adult with peptic ulcer disease

No additional information

2 Initial treatment

Offer H. pylori eradication therapy to people who have tested positive for H. pylori and who have
peptic ulcer disease.

For people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible.
Offer full-dose PPI (see table) or H2RA therapy for 8 weeks and, if H. pylori is present,
subsequently offer eradication therapy.

Proton pump inhibitor doses relating to evidence synthesis and recommendations in

clinical guideline 17

Proton pump Full/standard Low dose (on-demand

Double dose
inhibitor dose dose)

1
40 mg2 once a
Esomeprazole 20 mg once a day Not available
day

30 mg3 twice a
Lansoprazole 30 mg once a day 15 mg once a day
day

40 mg once a
Omeprazole 20 mg once a day 10 mg once a day
day

40 mg twice a
Pantoprazole 40 mg once a day 20 mg once a day
day

20 mg twice a
Rabeprazole 20 mg once a day 10 mg once a day
day

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1
Lower than the licensed starting dose for esomeprazole in gastro-oesophageal reflux disease, which is 40 mg, but
considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of dose-related effects, NICE
classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.
2
40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to
omeprazole 20 mg.
3
Off-label dose for gastro-oesophageal reflux disease.

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3 H. pylori testing and eradication

See Dyspepsia and gastro-oesophageal reflux disease / Helicobacter pylori testing and
eradication in adults

4 Proton pump inhibitor or H2 receptor antagonist therapy

Offer full-dose PPI (see table) or H2RA therapy for 4 to 8 weeks to people who have tested
negative for H. pylori who are not taking NSAIDs.

Proton pump inhibitor doses relating to evidence synthesis and recommendations in

clinical guideline 17

Proton pump Full/standard Low dose (on-demand

Double dose
inhibitor dose dose)

40 mg2 once a
Esomeprazole 20 mg1 once a day Not available
day

30 mg3 twice a
Lansoprazole 30 mg once a day 15 mg once a day
day

40 mg once a
Omeprazole 20 mg once a day 10 mg once a day
day

40 mg twice a
Pantoprazole 40 mg once a day 20 mg once a day
day

20 mg twice a
Rabeprazole 20 mg once a day 10 mg once a day
day

1
Lower than the licensed starting dose for esomeprazole in gastro-oesophageal reflux disease, which is 40 mg, but
considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of dose-related effects, NICE
classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.

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2
40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to
omeprazole 20 mg.
3
Off-label dose for gastro-oesophageal reflux disease.

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 Managing peptic ulcer disease in adults NICE Pathways

5 Endoscopy and retesting for H. pylori

Offer people with gastric ulcer and H. pylori repeat endoscopy 6 to 8 weeks after beginning
treatment, depending on the size of the lesion.

Offer people with peptic ulcer (gastric or duodenal) and H. pylori retesting for H. pylori 6 to 8
weeks after beginning treatment, depending on the size of the lesion.

Perform re-testing for H. pylori using a carbon-13 urea breath test. (There is currently
insufficient evidence to recommend the stool antigen test as a test of eradication.1)

6 Continued non-steroidal anti-inflammatory drug use

For people continuing to take NSAIDs after a peptic ulcer has healed, discuss the potential
harm from NSAID treatment. Review the need for NSAID use regularly (at least every 6 months)
and offer a trial of use on a limited, 'as-needed' basis. Consider reducing the dose, substituting
an NSAID with paracetamol, or using an alternative analgesic or low-dose ibuprofen (1.2 g
daily).

In people at high risk (previous ulceration) and for whom NSAID continuation is necessary,
consider a COX-2 selective NSAID instead of a standard NSAID. In either case, prescribe with a
PPI.

7 Unhealed ulcer

In people with an unhealed ulcer, exclude non-adherence, malignancy, failure to detect H. pylori,
inadvertent NSAID use, other ulcer-inducing medication and rare causes such as
ZollingerEllison syndrome or Crohn's disease.

NICE has produced a pathway on Crohn's disease.

8 If symptoms continue or recur

If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to
control symptoms. Discuss using the treatment on an 'as-needed' basis with people to manage
their own symptoms.

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Offer H2RA therapy if there is an inadequate response to a PPI.

9 Ongoing care

See dyspepsia and gastro-oesophageal reflux disease/dyspepsia and gastro-oesophageal

reflux disease in adults /Ongoing care

1
This refers to evidence reviewed in 2004.

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Managing peptic ulcer disease in adults NICE Pathways

Glossary

H. pylori

Helicobacter pylori

H2RA

H2 receptor antagonist

NSAID

non-steroidal anti-inflammatory drug

PPI

proton pump inhibitor

Sources

Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright

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or for commercial purposes, is allowed without the written permission of NICE.

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