Cimetidine, cigarette smoking, and recurrence of duodenal ulcer

Life events stress and psychosocial factors in men with peptic ulcer disease. II. Relationships with serum pepsinogen concentrations and behavioral risk factors

We examined in a controlled study whether psychologic disturbances in men with peptic ulcer disease were related to other potential ulcer "risk factors" (serum pepsinogen concentrations, cigarette smoking, and intake of alcohol, aspirin, or coffee). Psychopathology in general, personality features of hostility, irritability, and hypersensitivity, and impaired coping ability (low ego strength) each correlated significantly with serum pepsinogen concentration in ulcer patients (p less than or equal to 0.005). Cigarette smoking and intake of alcohol and aspirin were increased in ulcer patients but unrelated to psychopathology. Depression was the variable that best discriminated ulcer patients from nonulcer controls; a negative perception of life events, number of relatives with ulcer, and serum pepsinogen I concentration also had a major, unique discriminating value, whereas smoking played a relatively minor role independent of the other variables examined. Our study supports the concept that several interacting factors (psychologic, behavioral, and genetic/physiologic) are likely involved in peptic ulcer disease. Emotional stress may predispose to ulcers by producing gastric hypersecretion, as manifested by hyperpepsinogenemia.

Prostaglandin treatment for peptic ulcer

Prostaglandin analogues have been expected to outperform other antisecretory drugs as ulcer healing agents. This expectation arises from their ability to combine 'cytoprotection' with gastric secretory inhibition. Evidence of the existence of these two separate functions abounds in animals and in humans, but a clinical advantage has not evolved. Whereas most clinical trials show no difference between prostaglandin analogues and H2-receptor antagonists, some studies have shown the prostaglandins to be significantly less effective or no better than placebo. The role of cytoprotection in ulcer healing (as opposed to prevention) may be questioned and the present clinical role for these agents is unclear.

Factors which influence the incidence and course of peptic ulcer

The present review concentrates on environmental factors which influence the outcome of peptic ulcer disease by acting from the outside. Endogenous risk factors, such as acid output, pepsin secretion and serum pepsinogen, gastritis and mucosal defense, blood group, and secretor status, are only dealt with when they help to explain the mechanism by which exogenous risk factors affect the upper gastrointestinal mucosa. After outlining the wax and wane of peptic ulcer, it is concluded that these changes resulted from similar temporal patterns of occupational workload in the general population. Cross sectional studies also support the contention of occupational workload being a risk factor in peptic ulcer, explaining several characteristic features of peptic ulcer, such as its sex, race, and social class distribution, increased incidence in immigrant workers, seasonal variation, healing by bed rest, and urban versus rural distribution. Susceptible subjects may react to a rise in occupational workload and acute exposure to stressful life events by increased gastric secretion which, in turn, leads to ulceration and symptoms. Cigarette smoking, intake of aspirin and related drugs, dietary salt, and alcohol abuse represent additional environmental risk factors, which form the etiologic link of the association of peptic ulcer with chronic lung disease, rheumatoid arthritis, hypertensive disease, and liver cirrhosis, respectively.

Gastric emptying in smokers

We investigated the gastric emptying of a small solid meal in 21 healthy middle-aged men. Nine heavy smokers and 12 non-smokers were studied with a scintigraphic technique, using 99Tc-tin colloid as a tracer. All subjects had been instructed to abstain from smoking for at least 10 h before and during the examination. Smokers had on an average a shorter gastric emptying half-time (24.2 +/- 8.5 min) than non-smokers (40.6 +/- 14.1 min) (p less than 0.01). We conclude that habitual smoking has not only acute effects on gastric emptying but also a more long-standing influence.

Duodenal ulcer. Who should have long-term maintenance therapy?

Duodenal ulcer frequently recurs in some high-risk patients, particularly those who smoke. Maintenance therapy with H2-receptor antagonists or sucralfate reduces the recurrence rate and appears to be safe over a one-year period. Not all patients with healed duodenal ulcer are candidates for maintenance therapy, however, and selection should be based on evaluation of such risk factors as smoking habits, previous recurrence, and history of complications. Intermittent treatment of acute episodes may be an alternative.

Is duodenal ulcer really a psychosomatic disease? A population-based case-control study

Risk factors for prepyloric and duodenal ulcer were analysed by means of a questionnaire in 132 patients and 132 population controls, pairwise matched for age and sex. Several factors associated with a lower socioeconomic status, such as short education, low income and low housing standard, and a job characterized by low satisfaction, low demands, and low autonomy, were more prevalent among the patients. The odds ratio (OR) with 95% confidence limits (CL) in smokers versus non-smokers was 2.9 (CL, 1.7-5.0). A trend emerged in relation to the daily number of cigarettes, with an OR of 4.1 (CL, 2.2-7.5) for those smoking more than 10 cigarettes. The risk of having peptic ulcer disease was virtually unrelated to other psychiatric and somatic morbidity, to marital status, personal worries, type-A behaviour, experience of a hectic or psychologically demanding job, and to consumption of coffee, alcohol, and drugs. Our data lend no support to the concept that peptic ulcer disease is a disorder related to psychologic stress. Causative agents other than smoking should probably be sought among factors characterizing the life style of low socioeconomic classes.

Antisecretory and mucosal protective actions of misoprostol. Potential role in the treatment of peptic ulcer disease

Misoprostol, a synthetic methyl ester analogue of prostaglandin E1, inhibits basal, nocturnal, and stimulated gastric acid secretion. In doses of 400 to 1,200 micrograms daily, misoprostol accelerates the healing of duodenal and gastric ulcers in humans. In addition to its antisecretory actions, misoprostol has gastroduodenal mucosal protective (cytoprotective) effects in animals and in humans. In humans, these cytoprotective actions have been demonstrated in acid-dependent studies using non-antisecretory doses and in acid-independent studies using antisecretory doses. Patients with peptic ulcer disease may have a relative deficiency of mucosal prostaglandin synthesis as compared with nonulcer control subjects. In addition, patients who consume nonsteroidal anti-inflammatory drugs and those who are cigarette smokers may also have depressed gastric mucosal prostaglandin synthesis. There is some evidence that misoprostol reverses the deleterious effect of smoking on duodenal ulcer healing and that it is effective in treating and preventing mucosal damage induced by nonsteroidal anti-inflammatory drugs and alcohol.

Chronic duodenal and gastric ulcer

During the past two decades, major advances have been made in our understanding of basic gastric physiology. Appreciation of cellular biology has contributed to rapid progress in gastric pharmacology. Clinicians may choose from a large and rapidly growing list of antiulcer drugs. The proper choice of medical or surgical therapy depends on knowledge of the pathophysiology of peptic ulceration and of the inherent limitations of each approach. Selective drug use, tailoring of medical regimens to individual clinical situations, and the combination of medical and surgical treatments will play prominent roles in the future management of peptic ulceration.

Maintenance therapy for prevention of recurrent peptic ulcers

Peptic ulcer disease is a chronic, relapsing disease. Successful healing of duodenal and gastric ulcers with antacids, cimetidine, ranitidine, famotidine, or sucralfate is frequently followed by ulcer recurrence. The need for long-term, low-dose maintenance therapy is based on disease severity, ulcer history, complications, therapeutic intervention, response to treatment, and potential risk factors. Comparison of ulcer maintenance trials requires consideration of important factors such as frequency of endoscopy, duration of follow-up period, and the method used to calculate ulcer recurrence rates. Clinical trials indicate that chronic treatment with low-dose cimetidine, ranitidine, famotidine, and probably sucralfate decreases the frequency of duodenal ulcer recurrence and that ranitidine may be superior to cimetidine. Preliminary studies indicate that higher doses of these same medications may be required to prevent gastric ulcer recurrence. Long-term maintenance therapy with these agents must be continuous in order to prevent relapses, but treatment should be limited to one year because of unknown consequences beyond this period.

Survey of ulcer-recurrence risk factors associated with long-term cimetidine prescribing

The appropriateness of long-term cimetidine prescribing was evaluated retrospectively in 243 outpatients. Criteria defining appropriate indications for the use of cimetidine for longer than eight weeks were established. Of the 243 patients surveyed, 115 (47 percent) were considered to be inappropriately receiving long-term cimetidine, either because they had never been objectively studied radiographically or endoscopically (23 percent) or had negative results before initiation of therapy (24 percent). Risk factors known to be associated with recurrent peptic ulcer disease were reviewed. Patients fulfilling criteria for appropriate long-term cimetidine usage had a greater prevalence of risk factors compared to the nonjustifiable group. Of particular interest, individuals considered appropriate for long-term therapy were very likely to have had a gastrointestinal bleeding episode prior to beginning therapy (52 percent for gastric ulcer, 8 percent for the nonjustifiable group). This increased prevalence of gastrointestinal hemorrhage may be due to the inherent nature of peptic ulcer disease or a result of physicians selecting affected individuals who may benefit from long-term treatment. Eliminating inappropriate usage of long-term cimetidine in conjunction with a thorough evaluation of risk factors for recurrent ulcer disease can be useful in selecting those individuals most likely to benefit from long-term cimetidine therapy.

Maintenance treatment with cimetidine in peptic ulcer disease for up to 4 years

A multinational maintenance trial was conducted in 1842 peptic ulcer patients to investigate the efficacy and safety of continuous cimetidine maintenance therapy for up to 4 years. Patients with healed ulcers entered maintenance treatment with a 400-mg bedtime dose of cimetidine. Symptomatic ulcer relapse occurred in 17.2% of patients during the 1st year of treatment, in 9.6% during the 2nd year, and in 8.8% during the 3rd year. In addition to life-table analysis, the monthly prevalence of active ulceration over the 3-year period was examined. The average monthly prevalence rates were 2.1%, 1.8%, and 1.5% for the three successive yearly periods of continued cimetidine treatment. The adverse reactions observed in this study were not different from those previously reported with cimetidine. Moreover, there was a progressive decrease in the incidence of adverse events over the 4 years, thus establishing the long-term safety of continuous cimetidine treatment. It is concluded from this study that cimetidine maintenance treatment not only continues to be effective and safe beyond 1 year but also may reduce the risk of relapse over time.

Review: clinical trials in peptic ulcer disease--problems of methodology and interpretation

This review focuses on the methodology and interpretation of drug trials in peptic ulcer disease. The problems of planning and conduct that are discussed include the ethics of using placebo, eligibility criteria, estimations of sample size, stopping rules, randomization, blinding, and efficacy criteria, that is, ulcer healing and pain relief in the short term and prevention of relapse and complications in the long term. Statistical topics covered include confidence intervals, evaluation of survival type data, post-stratification, and sub-group analysis. The difference between clinical and statistical significance is discussed, major problems being overemphasis on P-value, type II errors, and post hoc power determinations. Explanatory and pragmatic questions are based on compliance-to-protocol and intention-to-treat cohorts, respectively, and involve problems of compliance testing, evaluation of withdrawals, and the use of fixed-dose regimens. The rather slow process for clinical trials to gain acceptance is described, and it is proposed to rely on disease-related and behavioural barriers, lack of knowledge of the inherent limitations of methodology, and overemphasis on the subject of peptic ulcer healing, in addition to some concern at the relevance of assessing long-term drug intervention by repeated endoscopies rather than by studying symptoms and the incidence of complications. We foresee an increased impact of clinical trials on ulcer research and therapeutic decision making, provided physicians are able to develop the proper methodology to answer the relevant questions.

Rational approach to long-term use of H2-antagonists

Although the approved indications for long-term histamine (H2) receptor-antagonists are limited to the management of hypersecretory states and prophylaxis against recurrent duodenal ulcer, these agents are often prescribed indiscriminately. Definitive guidelines concerning proper patient selection for prophylaxis against duodenal ulcer recurrence are lacking. Persons likely to benefit from maintenance therapy include those who smoke and those with a long duration of symptoms or prior history of an ulcer complication. Although not an approved indication, maintenance therapy to prevent recurrent gastric ulcer is appropriate for elderly persons receiving nonsteroidal anti-inflammatory drugs or in patients with poor cardiopulmonary status who may not tolerate surgery for an ulcer-related complication. The role of long-term H2-antagonist therapy in reflux esophagitis is not defined but may be appropriate in scleroderma and Barrett's esophagus. Finally, several miscellaneous conditions, including cystic fibrosis, Menetrier's disease, and pancreatic exocrine insufficiency, may benefit from long-term H2-antagonist therapy. Currently, clinical trials document the efficacy of maintenance therapy in duodenal ulcer for up to a three-year period; however, for gastric ulcer and chronic reflux esophagitis, the duration and benefit of long-term therapy is not established, and treatment regimens need to be individualized. Therapy may be required indefinitely in the miscellaneous states mentioned previously.

The effects of cigarette smoking on plasma concentrations of gastric antisecretory drugs

Plasma concentrations of cimetidine and ranitidine were measured after oral administration (n = 5 for cimetidine, n = 5 for ranitidine) or intravenous administration (n = 6 for cimetidine, n = 4 for ranitidine) in habitual smokers, once when cigarettes were smoked and again on a separate day when cigarettes were prohibited. After oral administration plasma concentrations of both drugs rose more rapidly and peak plasma concentrations were achieved earlier when cigarettes were smoked. However, plasma concentrations of the drugs subsequent to the peak were significantly lower when cigarettes were smoked. Cigarette smoking had no effect on plasma blood concentrations of either drug when administered intravenously. In eight healthy smokers cigarette smoking increased the gastric emptying of a liquid test meal by 28% compared with non-smoking control rates. In habitual smokers cigarette smoking alters the blood concentrations of antisecretory drugs in a manner which appears attributable to an increase in the rate of gastric emptying. The observed changes in drug disposition may contribute to the loss of gastric secretory inhibition observed in duodenal ulcer patients who are smokers.

Clinical markers of slow healing and relapsing gastric ulcer

The aim of the study was to identify the clinical markers useful in characterising slow healing and relapsing gastric ulcer patients. Ninety nine subjects entered the short term and 79 the long term study (12 months). The following parameters were taken into account: therapy, sex, age, smoking habit, alcohol consumption, analgesic intake, peptic ulcer family history and onset of the disease. Results of the studies were analysed by means of chi 2 test and logistic regression, both in stepwise and in specifying models. Cigarette smoking was found to be the most important risk factor of non-healing (p = 0.04). In women with late onset of the disease, cigarette smoking identified the gastric ulcer subjects at higher risk of non-healing with a predictive probability of 0.4679. Age under 50 years was found to be the most important risk factor of relapsing throughout the entire 12 month follow up period (p = 0.025). In those under 50 years, cigarette smoking and negative peptic ulcer family history in combination, identified the gastric ulcer subjects at higher risk of relapsing, the predicted probability being 0.6027. It is concluded that cigarette smoking is the most important risk factor for non-healing and those who relapse under the age of 50. The possibility of singling out categories of patients more prone not to heal and to relapse suggests new strategies in the management of gastric ulcer disease.

Overview of the mucosal protective effects of misoprostol in man

Misoprostol, a novel synthetic analog of prostaglandin E1 has been evaluated for its potential mucosal protective properties in healthy human subjects using randomized, double-blind, placebo-controlled studies. Misoprostol significantly reduced established aspirin-induced gastric microbleeding. Likewise, misoprostol significantly inhibited aspirin-induced fecal blood loss when administered concurrently with aspirin. The reduction of gastrointestinal blood loss was neither a consequence of the inhibition of gastric secretion, nor a change in aspirin absorption. In addition, misoprostol effectively attenuated the transmucosal potential difference drop induced by sodium taurocholate. In endoscopic studies, misoprostol significantly inhibited damage to the gastroduodenal mucosa induced by aspirin, tolmetin and ethanol. In the ethanol study, the protective effects of misoprostol were significantly and profoundly greater than that afforded by cimetidine administered at an effective gastric antisecretory dose. These studies indicate that misoprostol has mucosal protective property in man. The basis for this mucosal protective effect is not fully known, but laboratory and clinical evidence indicate a direct effect on the barrier functions of the stomach, an increased or maintenance of gastric mucosal blood flow and an enhanced mucus and bicarbonate secretion. The implications of these findings suggest that misoprostol may be useful in the prevention and treatment of acute gastroduodenal mucosal lesions and inflammation.

Nizatidine as maintenance therapy of duodenal ulcer disease in remission

A new H2-receptor antagonist, nizatidine (150 mg h.s.), was compared with placebo as maintenance therapy in a randomized, parallel, double-blind, one-year study of 513 patients with recently healed duodenal ulcer. Endoscopies were performed at 0, 3, 6, and 12 months and at unscheduled times if symptoms of active peptic ulcer disease were present. Cumulative ulcer recurrence rates for nizatidine and placebo were 13 versus 40% at 3 months, 24 versus 57% at 6 months, and 34 versus 64% at 12 months. The differences were significant (p less than 0.001) at each treatment period. Smokers in both treatment groups had significantly greater recurrence rates than non-smokers. Symptoms of peptic ulcer disease were significantly less in nizatidine-treated patients in the first 3 months of treatment. Adverse events, including those related to peptic ulcer disease, occurred more frequently in placebo-treated patients. Nizatidine proved to be safe and effective in preventing recurrences of duodenal ulcer.

Causative factors in the etiology of peptic ulcer disease become effective before the age of 15 years

Peptic ulcer mortality in Western Europe, Japan, and the United States is characterized by marked temporal changes which suggest that environmental factors are important in the etiology of gastric and duodenal ulcer. The present study examines at what age these factors start becoming effective. When the average age-specific death rates from 18 countries are plotted vs the year of birth, the fall of gastric and duodenal ulcer mortality related to successive birth-cohorts is continuously preserved in the age group of 15-19 years. Although the younger age groups also display a decline in ulcer mortality, it is not possible to discern unequivocally whether they follow the temporal pattern of birth-cohort risks. In the second analysis, the number of deaths from each individual country is accumulated over time, and the geographic variation in the age-specific mortality is compared for these countries. The death rates of consecutive age groups from different countries change in a parallel manner. The linear relationships between each two consecutive age groups start at the age of 5 years in gastric ulcer and at the age of 15 years in duodenal ulcer. These findings again suggest that the determinants for the risk of dying from gastric and duodenal ulcer begin to act at an age lower than 15. The contention of environmental factors starting to act before the age of 15 would remain valid, even if factors unrelated to etiology, such as different reporting for childhood and adult mortality, contributed to the different patterns of childhood and adult death rates. However, the actual cut-off age of gastric and duodenal ulcer would then be shifted towards younger ages.

A multicenter, double-blind, randomized, placebo-controlled comparison of nocturnal and twice-a-day famotidine in the treatment of active duodenal ulcer disease

The efficacy and safety of famotidine, a potent new long-acting H2-receptor antagonist, was compared with placebo in a multicenter, double-blind, randomized, placebo-controlled study in the United States. A total of 384 patients with endoscopically proven acute duodenal ulcer disease were enrolled. Patients received either famotidine or a placebo. The patients receiving famotidine were treated with one of three dose regimens, 40 mg h.s., 40 mg b.i.d., or 20 mg b.i.d. Patients were reassessed by endoscopy at 2, 4, and 8 wk if ulcer healing had not occurred sooner. A diary was kept to record the duration and intensity of the day and night pain and the amount of Gelusil antacid (Parke-Davis, Morris Plains, N.J.) ingested. Three hundred sixty-three patients met the evaluation criteria. The results revealed a 4-wk healing rate of 70%, 75%, 67%, and 31% for the famotidine 40 mg h.s., 40 mg b.i.d., 20 mg b.i.d., and placebo groups, respectively. The 8-wk healing rates for the same respective groups were 83%, 82%, 82%, 45%. Ulcer pain and antacid consumption occurred less often in the famotidine groups. The clinical and laboratory safety profile of the famotidine groups was similar to that of the placebo group. Famotidine appears to be an effective and safe once-a-day therapy for the treatment of acute duodenal ulcer disease. The recommended dosage is 40 mg h.s.

Smoking and mortality from peptic ulcer in the United Kingdom

The present paper compares the temporal changes of cigarette consumption with those of peptic ulcer mortality in the United Kingdom. Cumulative cigarette consumption increased in men born between 1845 and 1915 and remained constant or decreased in all subsequent generations. It increased in women born between 1835 and 1955. In contrast, both male and female mortality from gastric and duodenal ulcer were highest in those born around 1875-1885. From the lack of coincidence in the trends of peptic ulcer mortality and cumulative cigarette consumption it is concluded that changing smoking habits were not responsible for the birth cohort patterns of the death rates from gastric and duodenal ulcer.

Prostaglandins in peptic ulcer disease. An overview of current status and future directions

Naturally occurring prostaglandins almost certainly play an important role in maintaining the integrity of the gastrointestinal mucosa. Clinical evidence available to date indicates that synthetic analogues of prostaglandins heal gastroduodenal ulcer only in doses that suppress gastric acid. However, non-antisecretory doses of prostaglandins may eventually have a role in the treatment of ulcer disease by maintaining ulcer healing and preventing recurrence. This possibility along with the potential of prostaglandins to prevent gastroduodenal mucosal injury caused by NSAIDs, alcohol, aspirin and stress, if supported by the results of ongoing clinical trials, may prove to be a major therapeutic advance for the treatment of acid peptic disease.

A multicenter, randomized, double-blind study comparing famotidine with ranitidine in the treatment of active duodenal ulcer disease

Famotidine, a new long-acting histamine (H2)-receptor antagonist, has recently been shown to be more effective than placebo in healing active duodenal ulcer. In the current study, the efficacy and tolerability of famotidine were further investigated and compared with those of ranitidine in a multicenter, double-blind, randomized international study. Sixty-eight investigators from 19 countries enrolled 1,031 patients with endoscopically proven active duodenal ulcers. Patients received either ranitidine (150 mg twice daily) or famotidine at one of three different dosage regimens: 40 mg at bedtime, 40 mg twice daily, or 20 mg twice daily. Ulcer healing was assessed by serial endoscopy with pain relief and safety profiles also closely monitored. Nine hundred and eighty patients fulfilled the evaluation criteria. During the eight-week study, there was no significant difference in ulcer healing rates between the ranitidine control group and any of the famotidine treatment groups. At eight weeks, the healing rates were 87, 92, 92, and 90 percent for the famotidine (40 mg at bedtime, 20 mg twice daily, and 40 mg twice daily) and ranitidine groups, respectively. Ulcer pain improved and antacid consumption decreased in all the groups equally. The clinical and safety profiles were also similar in all four groups. This study indicates that famotidine used once or twice a day is as effective and well tolerated as twice-a-day ranitidine in the treatment of active duodenal ulcers, with the recommended dosage being 40 mg at bedtime. Furthermore, these data emphasize the importance of nocturnal acid secretion in the pathophysiology of duodenal ulcer disease.

In vitro inhibition of histamine metabolism in guinea pig lung by S-(-)-nicotine

S-(-)-Nicotine competitively inhibits the metabolism of histamine to its N tau-methylated derivative in guinea pig lung homogenates. S-(-)-Nicotine exhibited a dissociation constant of the enzyme:inhibitor complex, Ki, of 9.4 X 10(-5) M compared with Km's for histamine and co-factor, S-adenosylmethionine, of 4.74 X 10(-5) M and 1.76 X 10(-5) M, respectively. This demonstrates the first reported involvement of nicotine in histaminergic mechanisms.

Outpatient endoscopic survey of smoking and peptic ulcer

A survey of the smoking habits of 1217 outpatients undergoing upper gastrointestinal endoscopy was carried out over an 18 month period. Six hundred and twenty four were current smokers, 248 ex-smokers and 345 non-smokers. 11.9% of smokers had gastric ulcers, 7.7% of ex-smokers (p less than 0.025) and 4.6% of non-smokers (p less than 0.001). 2.8% of smokers had duodenal ulcers, 6.8% of ex-smokers (p less than 0.01) and 6.1% of non-smokers (p less than 0.001). There was a dose response effect between the number of cigarettes smoked and duodenal and gastric ulceration. Gastric cancer was also more frequent in smokers than non-smokers (p less than 0.01), but macroscopic oesophagitis less frequent (p less than 0.001). The results confirm the association between smoking and peptic ulcer.

Sex and smoking differences in duodenal ulcer mortality

Data from the US Census Bureau and the National Center for Health Statistics suggest that differences in male and female smoking habits between 1920 and 1980 may have contributed to changes in duodenal ulcer mortality sex ratios. An attributable risk analysis suggests that between 43 per cent and 63 per cent of duodenal ulcer mortality for males results from smoking; the comparable figures for females being between 25 per cent and 50 per cent.

Low dose maintenance treatment with cimetidine in duodenal ulcer: intermediate-term results

Ulcer relapse rates during up to 2 years of prophylactic low-dose maintenance therapy (LDMT) with cimetidine 400 mg at bedtime was examined in 261 patients. Endoscopy was repeated every 6 months if asymptomatic, or whenever symptoms recurred. Relapse was defined as the recurrence of an ulcer crater or erosions or both. In patients with non-refractory duodenal ulcer (those healed within 3 months) who comprise the majority, their likelihood of relapse at 6, 12, 18 and 24 months was: symptomatic 8%, 13%, 18%, 20%; silent 14%, 28%, 38%, 43%, respectively. In contrast, in patients with refractory ulcer, their symptomatic relapse rates were 36%, 45%, 46%, 48%, and silent 28%, 38%, 46%, 48% respectively. The outcome of a second course of LDMT was similar to the first. Narrowing the definition of relapse to exclude recurrence of erosions alone but without an ulcer decreased asymptomatic relapse in non-refractory ulcer patients by about half. No patient had any major side effects. Thus, LDMT is a safe and effective way of keeping most patients with duodenal ulcer symptom free over 2 years.

Therapeutic aspects of prostaglandins in the treatment of peptic ulcer disease

Studies of antisecretory compounds such as the H2-receptor antagonists have altered therapy and enhanced the understanding of peptic ulcer disease (PUD). While it is agreed that the dictum "no acid, no ulcer" is valid, acid hypersecretion does not appear to be the major determinant in a significant number of ulcer patients. More careful consideration of mucosal integrity in the pathogenesis of PUD is therefore necessary. A small but significant number of patients (5-15%) do not heal, despite the use of effective antiulcer drugs. Moreover, the posthealing recurrence rate may reach 75% after treatment is discontinued, and nearly one third of cigarette-smoking patients on maintenance therapy may suffer recurrences. Prostaglandins (PGs) are particularly important as potent antisecretory and effective antiulcer agents. In addition, recognition of their cytoprotective effects has stimulated research into the understanding and importance of mucosal protection and mucosal defense mechanisms. Animal studies show that PGs at nonantisecretory dosages prevent the development of gastric ulcers caused by virtually any insult. In humans, PGs prevent the mucosal damage caused by aspirin and ethanol. In some studies, the maintenance of normal mucosal integrity has been linked to normal mucosal production of PGs. Therefore, it is possible that exogenous PGs may be effective in patients whose ulcers do not heal with conventional therapy. They may reduce the recurrence of ulcers, particularly in those patients whose defect in mucosal integrity appears to be the major problem. Furthermore, in those patients subjected to the toxic effects of alcohol ingestion, nonsteroidal antiinflammatory drugs, antineoplastic drugs, and stress, exogenous PGs may prevent mucosal lesions. As such, PGs could be the ideal antiulcer drug.

Efficacy of misoprostol (twice daily dosage) in acute healing of duodenal ulcer. A multicenter double-blind controlled trial

This study was undertaken to evaluate the efficacy of misoprostol taken twice daily for the healing of duodenal ulcer. Three hundred thirty patients with endoscopically proven duodenal ulcer participated in a multicenter, double-blind, controlled trial comparing placebo with misoprostol 200 micrograms and 400 micrograms twice daily for up to four weeks. Patient characteristics were similar in all three treatment groups. Ulcers were between 0.3 cm and 2.0 cm in length. Healing was determined by endoscopy at two weeks; if ulcers were not healed, endoscopy was repeated at four weeks. All patients were given Al(OH)3 antacid (up to 54 meq a day) to be used as needed for pain. Healing rates at four weeks for a total of 280 evaluable patients in the three treatment groups were as follows: misoprostol 400 micrograms bid, 65.4%; misoprostol 200 micrograms bid, 52.9%; and placebo, 42.2%. Misoprostol 400 micrograms bid was superior to placebo (P = 0.002) in healing ulcers. However, the healing rate for misoprostol 200 micrograms bid did not differ significantly from placebo. The percentage of nonsmokers who healed at four weeks was higher than that of smokers in both misoprostol-treatment groups, although the difference was not analyzed for statistical significance. There were no differences in antacid consumption or pain relief among the three experimental groups during the study. Diarrhea was the most common side effect but was mild and self-limiting, occurring in 8.9%, 5.9%, and 1.8% of the misoprostol 400 micrograms, 200 micrograms, and placebo groups, respectively. These results indicate that misoprostol 400 micrograms taken twice daily for four weeks is effective and safe for the treatment of duodenal ulcers.

Clinical perspectives of drugs inhibiting acid secretion: histamine H2 antagonists

The present report shows that the following statement is correct: 'Uncomplicated peptic ulcer is best treated with a strongly acting histamine antagonist given once daily with dinner for 4 weeks and by abstention from smoking'.

Cigarette smoking, gastric acid secretion, and serum pepsinogen I concentrations in duodenal ulcer patients

Cigarette smoking has been linked with duodenal ulcer disease although the mechanism of this association is unclear. This study assessed basal gastric secretory response to acute smoking of smokers with an active duodenal ulcer; in addition the possible effects of chronic smoking on gastric secretory capacity, as expressed by pentagastrin stimulated gastric acid secretion and fasting serum pepsinogen I (PG I) concentrations, were investigated in patients with active duodenal ulcer, or non-ulcer dyspepsia. In 10 smokers with duodenal ulcer smoking four cigarettes during 40 minutes did not influence basal gastric secretion of acid and pepsin, or serum PG I and gastrin concentrations. In 136 patients with duodenal ulcer and 90 controls with non-ulcer dyspepsia, pentagastrin stimulated acid secretion and fasting serum PG I concentrations were significantly higher among habitual heavy smokers than among non-smokers. These findings suggest that in heavy smokers with duodenal ulcer acid- and pepsin-secreting cell function is not affected by acute cigarette smoking. By contrast, chronic cigarette smoking seems to be associated either with an increase of parietal- and chief-cell mass, or with an enhancement of their secretory capacity.

Cigarette smoking and duodenal ulcer

Tobacco smoking delays healing of gastric ulcer and may influence duodenal ulceration. Seventy men, all cigarette smokers, were found to have duodenal ulceration at endoscopy. All were advised to stop smoking and received a three-month course of cimetidine. Endoscopy was repeated at three months (n = 63) and at six months (n = 56). At three months most (79%) patients showed ulcer healing and there was no difference between men who had and had not stopped smoking. At six months, however, a higher proportion (61% vs 28%, p less than 0.05) of smokers (n = 38) than ex-smokers (n = 18) had duodenal ulceration. This difference reflected a combination of increased ulcer persistence and ulcer relapse. Neither cimetidine nor cigarette smoking nor ulcer healing appeared substantially to affect duodenitis and fixed deformity. We conclude that continued cigarette smoking does not prevent the powerful duodenal ulcer healing effect of cimetidine but does predispose to an increased expectation of duodenal ulceration soon after cimetidine has been stopped.

Misoprostol in the treatment of duodenal ulcer. A multicenter double-blind placebo-controlled study

Patients with endoscopically documented duodenal ulcer participated in a double-blind, multicenter trial comparing placebo with misoprostol 100 micrograms administered q.i.d. for up to four weeks in the treatment of duodenal ulcer. Ulcers were examined endoscopically at two weeks and, if not healed, again at four weeks. Acetaminophen was permitted for pain relief. At four weeks, of 286 patients admitted to the study, the cumulative healing rate for the 227 evaluable patients was 64.9% for misoprostol and 47.4% for placebo (P = 0.008). Misoprostol was also significantly superior to placebo in promoting ulcer healing when all patients entering the study (intent-to-treat cohort) were compared (P = 0.018), and in a modified intent-to-treat cohort consisting of all patients whose final endoscopic results were known (P = 0.005). Ulcer symptoms were similar in both treatment groups, and most patients in both groups were pain free at the end of the first two weeks of treatment. Diarrhea was the most frequently reported adverse experience (8.5% for misoprostol and 3.5% for placebo). This symptom was mild and self-limiting in spite of continued use of misoprostol. We conclude that misoprostol 100 micrograms q.i.d. for four weeks is safe and effective in the healing of duodenal ulcers.