Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease

The Success of Histamine-2 Receptor Antagonists

The lives of both patients and doctors have been revolutionized since the development of histamine-2 receptor antagonists. Their development has introduced, for the first time, a rapid, reliable, and save means of healing both duodenal and gastric ulceration. The continuous administration of these agents has additionally been shown to reduce ulcer relapse and subsequent complications. In addition, they offer some protection from the development of nonsteroidal anti-inflammatory drug-induced damage. The symptomatic relief of reflux together with healing of oesophagitis has been of further benefit. The drugs in this group have become one of the most widely used ethical pharmaceuticals in the world, with ranitidine (Zantac) as the biggest-selling drug in the world for the last few years. Their success can be attributed to their simplicity of use, safety, and above all, their efficacy. Their current role in gastroenterologic practice, in the face of new developments such as Helicobacter eradication and the development of proton pump inhibitors, will be discussed.

The need for long-term treatment of peptic ulcer

Some 10% of the population in Western countries will suffer a duodenal ulcer or gastric ulcer at some time in their lives. Although there has been an improvement in the survival rate of patients with peptic ulcer haemorrhage, the mortality is still approximately 10%. There is evidence to suggest that peptic ulcer disease is a life-long condition and that ulcers remain active with an unchanged potential for complications such as haemorrhage and perforation. Over the past 15 years anti-ulcer drugs with different mechanisms of action have been developed, and their use results in complete healing of an ulcer in four to eight weeks. However, most patients experience recurrence of their peptic ulcer after discontinuation of the healing therapy. Studies of continuous H2-receptor antagonist therapy have shown that recurrence occurs less frequently than in untreated patients, is largely asymptomatic, and is rarely characterized by haemorrhagic complications. Limited data on therapy for the eradication of Helicobacter pylori suggest that this may be an alternative approach for selected patients. As protection afforded by H2-receptor antagonists remains undiminished over the course of several years and is also observed in ulcers which have bled in the past, the implementation of long-term management with these agents constitutes a rational policy.

A decade of experience with long-term continuous treatment of peptic ulcers with H2-receptor antagonists

Patients with peptic ulcer disease are troubled by recurrent episodes of ulcer pain, and remain at risk of developing the serious and occasionally lethal complications of haemorrhage and perforation. As the disease is chronic and persists over many years, a long-term strategy for the management of patients with peptic ulcer is required. Continuous, long-term treatment with H2-receptor antagonists successfully achieves the dual objectives of preventing painful ulcer recurrence and reducing the risk of complications. During nine years of continuous therapy with ranitidine, more than 80% of patients with duodenal ulcers remain free from symptomatic ulcer recurrence, less than 2% suffer from ulcer haemorrhage, and the risk of perforation is 0%. Similar beneficial effects of long-term treatment have been observed in patients with gastric ulcer. Long-term continuous treatment with H2-receptor antagonists may not alter the natural history of ulcer disease. Even after seven years of continuous therapy with ranitidine, ulcers recur in 50% of patients within six months of stopping treatment. Hence, long-term therapy with H2-receptor antagonists may need to be continued beyond 10 years. Patients with peptic ulcer who are elderly, those taking NSAIDs, aspirin or anti-coagulants, those with a previous history of an ulcer complication and those with serious co-existent disease are at increased risk from haemorrhage and perforation. These patients should receive long-term prophylactic therapy with an H2-receptor antagonist.

Efficacy of continuous therapy for peptic ulcer in controlled clinical trials

Long-term studies have confirmed unequivocally the clinical efficacy of continuous therapy with H2-receptor antagonists in reducing the incidence of ulcer recurrence. However, studies have also reported varying relapse rates as a result of differences in study design, particularly the frequency of endoscopy and hence the detection of asymptomatic ulcer relapse. Risk factors for ulcer relapse include smoking, stress, previous history of frequent ulcer relapses, duration of disease for more than 10 years and concomitant administration of non-steroidal anti-inflammatory drugs. In the prevention of relapse with H2-receptor antagonists, choice of agents also may influence the rate of relapse. A meta-analysis of data from direct comparative trials indicates that recurrence rates of duodenal ulcer are significantly lower after one year of treatment with ranitidine (150 mg nocte) than with cimetidine (400 mg nocte). It has been claimed that patients with peptic ulcer disease can be successfully managed by intermittent courses of treatment with H2-receptor antagonists which are taken in response to the development of symptoms. However, high relapse rates (64-100%) have been reported during the first year of follow-up of patients who were receiving intermittent treatment with H2-receptor antagonists. High complication rates (haemorrhage 11.4%, perforation 1.2%) have also been reported over a seven-year follow-up, while continuous treatment with H2-receptor antagonists significantly decreases the risk of haemorrhage in the event of ulcer recurrence.

Meta-analysis: Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer

AIM

To perform a meta-analysis comparing the efficacy of Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer.

METHODS

A search was made of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and several congresses for controlled clinical trials comparing the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of peptic ulcer re-bleeding. Studies with all patients taking non-steroidal anti-inflammatory drugs were excluded. Extraction and quality assessment of the studies were performed by two reviewers.

RESULTS

In the first meta-analysis, the mean percentage of re-bleeding in the H. pylori eradication therapy group was 4.5%, compared with 23.7% in the non-eradication therapy group without long-term antisecretory therapy [odds ratio, 0.18; 95% confidence interval (CI), 0.09-0.37; 'number needed to treat' (NNT), 5; 95% CI, 4-8]. In the second meta-analysis, the re-bleeding rate in the H. pylori eradication therapy group was 1.6%, compared with 5.6% in the non-eradication therapy group with maintenance antisecretory therapy (odds ratio, 0.25; 95% CI, 0.08-0.76; NNT, 20; 95% CI, 12-100). When only patients with successful H. pylori eradication were included, the re-bleeding rate was 1%.

CONCLUSIONS

The treatment of H. pylori infection is more effective than antisecretory non-eradication therapy (with or without long-term maintenance antisecretory treatment) in the prevention of recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori, and eradication therapy should be prescribed to infected patients.

H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer

BACKGROUND

Peptic ulcer is the main cause for upper gastrointestinal haemorrhage, and Helicobacter pylori infection is the main etiologic factor for peptic ulcer disease. Maintenance antisecretory therapy has been the standard long-term treatment for patients with bleeding ulcers to prevent recurrent bleeding. On the other hand, the precise efficacy of H. pylori eradication for the prevention of rebleeding from peptic ulcer is unknown.

OBJECTIVES

To compare the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (the Cochrane Library issue 4, 2003), MEDLINE (January 1966 to January 2004), EMBASE (January 1988 to January 2004), CINAHL (January 1982 to January 2004), and reference lists of articles. We also conducted a manual search from several congresses.

SELECTION CRITERIA

Controlled clinical trials comparing the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer.

DATA COLLECTION AND ANALYSIS

Extraction and quality assessment of studies were done by two reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Seven studies with a total of 578 patients were included in the first meta-analysis: mean percentage of rebleeding in H. pylori eradication therapy group was 2.9%, and in the non-eradication therapy group without subsequent long-term maintenance antisecretory therapy it was 20% (OR 0.17, 95% CI 0.10 to 0.32; there was no statistical evidence of heterogeneity; NNT was 7, 95% CI 5 to 11). Three studies with a total of 470 patients were included in the second meta-analysis: mean percentage of rebleeding in H. pylori eradication therapy group was 1.6%, and in non-eradication therapy group with long-term maintenance antisecretory therapy it was 5.6% (OR 0.25, 95% CI 0.08 to 0.76; heterogeneity was not demonstrated; NNT was 20, 95% CI 12 to 100). SUBANALYSIS: Excluding patients taking non-steroidal anti-inflammatory drugs (NSAIDs) at the time of recurrent bleeding resulted in a rebleeding rate of 2.7% (first meta-analysis) or 0.78% (second meta-analysis) in the group receiving H. pylori eradication therapy. When only patients with H. pylori eradication success were included, rebleeding rate was 1.1% in H. pylori eradication therapy group, and NNT decreased from 7 to 6. In some cases, recurrence of H. pylori infection seemed to be responsible for recurrence of bleeding.

REVIEWERS' CONCLUSIONS

Treatment of H. pylori infection is more effective than antisecretory non-eradicating therapy (with or without long-term maintenance antisecretory therapy) in preventing recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori infection, and eradication therapy should be prescribed to H. pylori-positive patients.

H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer

BACKGROUND

Peptic ulcer is the main cause for upper gastrointestinal haemorrhage, and Helicobacter pylori infection is the main etiologic factor for peptic ulcer disease. Maintenance antisecretory therapy has been the standard long-term treatment for patients with bleeding ulcers to prevent recurrent bleeding. On the other hand, the precise efficacy of H. pylori eradication for the prevention of rebleeding from peptic ulcer is unknown.

OBJECTIVES

To compare the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (the Cochrane Library issue 1, 2003), MEDLINE (January 1966 to March 2003), EMBASE (January 1988 to March 2003), CINAHL (January 1982 to March 2003), and reference lists of articles. We also conducted a manual search from several congresses.

SELECTION CRITERIA

Controlled clinical trials comparing the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer.

DATA COLLECTION AND ANALYSIS

Extraction and quality assessment of studies were done by two reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Six studies with a total of 355 patients were included in the first meta-analysis: mean percentage of rebleeding in H. pylori eradication therapy group was 4.5%, and in the non-eradication therapy group without subsequent long-term maintenance antisecretory therapy it was 23.7% (OR 0.18, 95% CI 0.09 to 0.37; there was no statistical evidence of heterogeneity; NNT was 5, 95% CI 4 to 8). Three studies with a total of 470 patients were included in the second meta-analysis: mean percentage of rebleeding in H. pylori eradication therapy group was 1.6%, and in non-eradication therapy group with long-term maintenance antisecretory therapy it was 5.6% (OR 0.25, 95% CI 0.08 to 0.76; heterogeneity was not demonstrated; NNT was 20, 95% CI 12 to 100). Subanalysis. Excluding patients taking non-steroidal anti-inflammatory drugs (NSAIDs) at the time of recurrent bleeding resulted in a rebleeding rate of 4% (first meta-analysis) or 0.78% (second meta-analysis) in the group receiving H. pylori eradication therapy. When only patients with H. pylori eradication success were included, rebleeding rate was 1% in H. pylori eradication therapy group, and NNT decreased from 5 to 4. In some cases, recurrence of H. pylori infection seemed to be responsible for recurrence of bleeding.

REVIEWER'S CONCLUSIONS

Treatment of H. pylori infection is more effective than antisecretory non-eradicating therapy (with or without long-term maintenance antisecretory therapy) in preventing recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori infection, and eradication therapy should be prescribed to H. pylori-positive patients.

Effect of Helicobacter pylori eradication on duodenal ulcer scar in patients with no clinical history of duodenal ulcer

BACKGROUND

Helicobacter pylori eradication has become the standard treatment for duodenal ulcer. However, there is no relevant evidence for antibacterial treatment of the white scar stage of duodenal ulcer (duodenal ulcer scar) in patients with no past history of duodenal ulcer.

AIM

To investigate whether H. pylori eradication could decrease duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

PATIENTS AND METHODS

We prospectively enrolled 66 patients with duodenal ulcer scar: 53 were H. pylori-positive and 13 were H. pylori-negative. H. pylori-positive patients were randomly assigned into two groups (two-to-one allocation): 36 patients were assigned to the treatment group and 17 to the follow-up group. Thirteen H. pylori-negative patients were followed up according to the study protocol. Follow-up endoscopy was performed to evaluate ulcer scar changes and H. pylori status 6 weeks after anti-H. pylori treatment and then every 6 months for up to 30 months.

RESULTS

Active duodenal ulcer recurrence was identified in seven of 23 H. pylori-positive/non-cured patients (30%). There was no duodenal ulcer recurrence in 43 H. pylori-negative/cured patients (0%), which was significantly different in terms of duodenal ulcer recurrence (P=0.001).

CONCLUSIONS

H. pylori eradication is effective at preventing active duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

Eradication of H. pylori with pantoprazole, clarithromycin, and metronidazole in duodenal ulcer patients: a head-to-head comparison between two regimens of different duration

BACKGROUND

The study was conducted to compare the efficacy and tolerability of two pantoprazole-based triple therapies of different length in the eradication of H. pylori.

METHODS

In this double-blind, multicenter parallel group comparison, H. pylori-positive patients were randomly assigned to either the PCM-7 group (7 days of pantoprazole 40 mg bid, clarithromycin 500 mg bid, metronidazole 500 mg bid) or the PCM-14 m group (modified 14 day therapy of the same regimen with metronidazole only given for 10 days due to labeling reasons). H. pylori status was determined by urease test, histology, culture, and 13C-urea breath test. Treatment outcome was assessed 6 weeks after intake of the last study medication.

RESULTS

The following eradication rates were achieved: for PCM-7 in the MITT population 83% (89/107), in the PP population 84% (81/97); for PCM-14 m in MITT 87% (92/106), in PP 88% (91/104). Ulcer healing rates were: for PCM-7 in MITT population 99% (106/107), in the PP population 99% (96/97); for PCM-14 m in MITT 99% (105/106), in PP 99% (103/104). Gastrointestinal symptoms and gastritis scores decreased in both treatment groups. Equivalence of treatment regimens could be proven for all populations. In total, 64 patients reported adverse events. Five serious adverse events occurred, all unrelated to the study medication.

CONCLUSION

The two pantoprazole-based triple therapies tested in this study are equally effective in H. pylori eradication, ulcer healing and relief from ulcer pain. It is concluded that 7 days of triple therapy are generally sufficient.

Lansoprazole versus omeprazole for duodenal ulcer healing and prevention of relapse: a randomized, multicenter, double-masked trial

The aim of this randomized, multicenter, double-masked, parallel-group study was to compare the efficacy of lansoprazole with that of omeprazole monotherapy in duodenal ulcer healing and prevention of relapse. A total of 251 patients with duodenal ulcer were treated with either lansoprazole 30 mg/d (n = 167) or omeprazole 40 mg/d (n = 84). Patients with healed ulcers were then randomly allocated to 12 months of maintenance therapy with lansoprazole 15 mg/d (n = 74), lansoprazole 30 mg/d (n = 71), or omeprazole 20 mg/d (n = 73). Healing rates at 4 weeks (intent-to-treat analysis) were 93.9% (95% confidence interval [CI], 90.2% to 97.6%) with lansoprazole and 97.5% (95% CI, 93.7% to 100%) with omeprazole; there were no significant differences between groups. Endoscopic relapse rates after 6 months were 4.5% (95% CI, 0% to 10.6%) with lansoprazole 15 mg, 0% with lansoprazole 30 mg, and 6.3% (95% CI, 1.5% to 12.5%) with omeprazole 20 mg, compared with 3.3% (95% CI, 0% to 8.2%), 0%, and 3.5% (95% CI, 0% to 8.8%), respectively, at 12 months. Again, there were no significant differences between groups. The incidence of adverse events during acute treatment was 6.0% and 7.1% in the lansoprazole and omeprazole groups, respectively; during maintenance therapy, the incidences were 12.2% (lansoprazole 15 mg), 5.6% (lansoprazole 30 mg), and 11.0% (omeprazole 20 mg). Within treatment groups, pain was significantly ameliorated after the acute phase but not after maintenance therapy (P < 0.05); no differences were observed between groups. Gastrin values increased significantly after acute therapy (P < 0.05), persisted at these increased levels during maintenance therapy, and returned to normal after 6-month follow-up. Both lansoprazole and omeprazole were highly effective and well tolerated in the treatment of duodenal ulcer; relapse rates were similar for all doses studied. Thus no additional benefit is to be gained from using a proton-pump inhibitor at a dose > 15 mg lansoprazole to prevent relapse.

Double-blind comparison of lansoprazole 15 mg, lansoprazole 30 mg and placebo as maintenance therapy in patients with healed duodenal ulcers resistant to H2-receptor antagonists

BACKGROUND

Maintenance antisecretory therapy is often used to prevent duodenal ulcer recurrence and control symptoms. This study compared the efficacy and safety of lansoprazole 15 mg and 30 mg daily with placebo in preventing ulcer recurrence in patients with a recent history of duodenal ulcer disease.

METHODS

Fifty-six patients were treated with either lansoprazole 15 mg, 30 mg or placebo o.m.

RESULTS

Within 1 month of study initiation, 27% (four out of 15) of placebo-treated patients experienced ulcer recurrence as compared to 13% (two out of 15) and 6% (one out of 18) of lansoprazole 15 mg and 30 mg treated patients, respectively. Median time to first ulcer recurrence was > 12 months in lansoprazole patients. At Month 12, significantly (P < 0.001) more lansoprazole 15 mg patients (70%) and lansoprazole 30 mg patients (85%) remained healed. Eighty-two per cent of lansoprazole 15 mg and 76% of lansoprazole 30 mg patients remained asymptomatic during the entire study period. All placebo patients became symptomatic, experienced ulcer recurrence, or withdrew from the study by month six. The incidence of adverse events was comparable among the three treatment groups.

CONCLUSIONS

Lansoprazole safely and effectively reduces duodenal ulcer recurrence and ulcer-related symptoms.

Triple versus dual therapy for eradicating Helicobacter pylori and preventing ulcer recurrence: a randomized, double-blind, multicenter study of lansoprazole, clarithromycin, and/or amoxicillin in different dosing regimens

OBJECTIVE

The efficacy and safety of dual and triple therapies with a proton pump inhibitor and antibiotic(s) for therapy of Helicobacter pylori-associated duodenal ulcer disease have been compared using results from independent studies using different methods and regimens, making interpretation difficult. In a large, double-blind, multicenter study conducted in the United States, we compared a triple therapy regimen with four dual therapy and one monotherapy regimens in the eradication of H. pylori and the prevention of ulcer recurrence.

METHODS

Patients with active duodenal ulcer disease or history of duodenal ulcer disease within the past year and H. pylori infection were randomized to receive one of six 14-day treatment regimens: lansoprazole 30 mg, clarithromycin 500 mg, and amoxicillin 1 gm b.i.d.; lansoprazole 30 mg b.id. and either clarithromycin 500 mg b.i.d. or t.i.d.; lansoprazole 30 mg b.i.d. or t.i.d. with amoxicillin 1 gm t.i.d.; or lansoprazole 30 mg t.i.d. alone. No additional acid suppression therapy followed eradication therapy. Primary efficacy endpoints were eradication of H. pylori and ulcer recurrence.

RESULTS

Of 396 patients enrolled in the study, 352 met the entry criteria for duodenal ulcer status and H. pylori positivity. At 4-6 wk after the end of therapy, H. pylori was eradicated from 94% (44 of 47) of patients receiving lansoprazole, clarithromycin, and amoxicillin triple therapy, 77% (39 of 51) of those receiving lansoprazole t.i.d./amoxicillin t.i.d., 75% (36 of 48) of those receiving lansoprazole b.i.d./clarithromycin t.i.d., 57% (28 of 49) of those receiving lansoprazole b.i.d./clarithromycin b.i.d., 53% (26 of 49) of those receiving lansoprazole b.i.d./amoxicillin t.i.d., and 2% (1 of 53) of those receiving lansoprazole monotherapy (p < or = 0.05, triple therapy vs each dual therapy and each dual therapy vs monotherapy). Of those patients who were documented as free of ulcer at 4-6 wk after treatment, ulcers recurred within 6 months in 7% of patients receiving triple therapy, as compared with 13-23% of patients receiving dual therapy, and 69% of patients receiving lansoprazole monotherapy. Patients who were H. pylori negative at 4-6 wk after treatment were less likely to have an ulcer recurrence than were patients who were H. pylori positive (11% [10 of 95] vs 47% [20 of 43], respectively, across treatment groups). For triple therapy and dual therapy, a similar proportion of patients reported a drug-related adverse event (23% vs 17-33%, respectively).

CONCLUSIONS

In patients with active or a recent history of duodenal ulcer, a 14-day course of lansoprazole-based triple therapy without additional acid suppression therapy is highly effective in the eradication of H. pylori and in preventing ulcer recurrence. Among the dual therapies, higher eradication rates occurred when lansoprazole (with amoxicillin) or clarithromycin (with lansoprazole) was administered t.i.d. vs b.i.d., but the rates were still significantly lower than with lansoprazole triple therapy with all three drugs administered b.i.d.

The long-term management of patients with bleeding duodenal ulcers

BACKGROUND

Gastrointestinal haemorrhage is a common complication of duodenal ulcers. Patients who bleed are at substantial risk of recurrent bleeding.

AIM

To determine whether appropriate therapeutic steps were taken to reduce the risk of recurrent haemorrhage in patients with a bleeding duodenal ulcer.

METHODS

The management of patients surviving a duodenal ulcer bleed in the University Hospital. Nottingham, was assessed by case-note review before (1993) and after (1995-1996) institution of clinical guidelines. The following measures aimed at reducing the risk of recurrent haemorrhage were considered appropriate: stopping non-steroidal anti-inflammatory drugs (NSAIDs) when these were implicated in bleeding; successful eradication of Helicobacter pylori if present; and long-term maintenance acid-suppression therapy.

RESULTS

In 1993, appropriate steps were taken to reduce the risk of recurrent haemorrhage in only 48% of cases. Following the institution of guidelines, management improved significantly in 1995-1996 (appropriate in 83% of cases, P < 0.001), was associated with increased referral to gastroenterologists (P < 0.001), improved patient compliance with follow-up (P < 0.05), and more rigorous attempts to identify (P < 0.001) and ensure clearance (P < 0.001) of H. pylori.

CONCLUSION

In this study, inadequate long-term management of patients with a bleeding duodenal ulcer was common. This was to a failure to adopt strategies aimed at reducing the risk of ulcer relapse and rebleeding. The quality of care improved significantly following the institution of guidelines and encouragement to refer to gastroenterologists.

Treatment of Helicobacter pylori infection

Helicobacter pylori infection is now recognised as the major cause of chronic active gastritis and peptic ulcer disease and eradication of the infection will prevent recurrence of the majority of such ulcers. A large number of different treatment combinations have been tried, but 100% H pylori eradication has not been achieved due to the use of wrong drug combinations or dosages, non-compliance and development of primary or acquired bacterial resistant strains. However, consistent 95-96% H pylori eradication can now be achieved with triple therapy employing a high-dose proton pump inhibitor twice daily together with any two of the following drugs: nitroimidazole, clarithromycin, or amoxycillin in appropriate dosages taken two to three times daily and all concurrently for one week. The problem of resistant bacterial strains has to be addressed, as this development is one of the consequences of failed eradication treatment.

Audit of the outcome of peptic ulcer disease diagnosed 10 to 20 years previously

METHODS/AIMS: During 1993-1994 an audit of the outcomes of a consecutive series of peptic ulcer patients, first diagnosed endoscopically between 1972-1983, was carried out. Three hundred and thirty six patients fitting the entry criteria were identified, 46 had died in the interval, and 44 were lost to follow up, leaving 246 available for evaluation. All patients completed questionnaires on their current symptomatic state, drug treatment, and details of any operations they had undergone since their original diagnosis. In addition they were asked to indicate, on an analogue scale, their overall assessment of how their ulcer problem was affecting them at the time of the review. Where available hospital records were obtained and analysed for any further admissions and the results of any further endoscopies.

RESULTS

Of the 246 patients, 158 were men and 88 female. Duodenal ulcers (DU) were present in 204 and gastric ulcers (GU) in 51 (nine had both a DU and GU). Since the diagnosis 65 patients had undergone surgical treatment: 44 for poor ulcer control, nine for pyloric stenosis, nine for a perforation, one for a major gastrointestinal bleed, and two for a gastric carcinoma developing within two years of the diagnosis of a GU. The overall incidence of ulcer complications during this follow up period (excluding the carcinomas) was 7.7%. Initial medical treatment was with histamine H2 blockade in 234 patients--87.4% cimetidine (C) and 11% ranitidine (R)--with other agents in the remainder. At follow up 176 patients were still receiving medical treatment (C, 71%: R, 22%, other, 7%) including 30 who had previously undergone a definitive surgical procedure. Dyspeptic symptoms were recorded in 50.4% of the patients, abdominal pain being the commonest complaint. There was a significant relation between abdominal pain and the analogue scores provided by the patients with significantly more (p = 0.02) of those who had undergone surgical treatment recording this as a continuing problem (44.6% v 36%).

CONCLUSION

There is no evidence provided by this study that, in these patients, their ulcer disease is undergoing spontaneous remission with time.

The natural course of peptic ulcer disease and its predictors

BACKGROUND

Little is known about today's natural course of peptic ulcer disease (PUD).

METHODS

A follow-up study based on a structured telephone interview was attempted in 728 patients with an endoscopic diagnosis of peptic ulcer in 1980-84.

RESULTS

Seven patients (1%) died because of PUD during the 8- to 10-year follow-up period. Of the 441 interviewed patients 15.2% had experienced no further clinical manifestations of PUD, 10.9% had had bleeding and 0.7% perforation, and 17.5% had been operated on. The operated patients reported fewer symptoms (p < 0.01) during the last 2 weeks before the interview than those not operated on. On an average the unoperated patients had had symptoms and had used histamine-2-receptor antagonists (H2RA) 12 and 10 weeks per year, respectively. Long-term treatment with H2RA was reported by 18%. More than one-third (36%) of the unoperated patients stated that the symptoms had had a significant negative impact on their lives. Age at onset of disease and index ulcer, family history, use of anti-inflammatory drugs and alcohol, bleeding, and another chronic disease were found to be significant predictors of the course.

CONCLUSION

In more than one-third of the patients with PUD the course is still burdened with many symptoms and complications.

On the natural history of peptic ulcer

BACKGROUND

Three out of 1000 individuals have peptic ulcer every year, and 20% of the ulcer episodes are associated with bleeding. Whether major innovations such as endoscopy and strong acid-suppressing drugs have had any impact on the natural course of peptic ulcer disease is largely unknown.

METHODS

Three hundred and fifty-one patients (median age, 63 years) with endoscopically proven peptic ulcer during 1979-1984 were included in the study and retrospectively followed up via medical records. The total population is based on two different groups of patients, the first comprising 229 consecutively diagnosed ulcer patients during 1979-81 and, to increase the number of bleeders, a second group including 122 bleeding ulcer patients consecutively diagnosed during 1981-84. At the end of the follow-up period all non-ulcer-operated patients were asked to answer a questionnaire on symptoms, investigations, and medication.

RESULTS

The male to female ratio was 2.4:1 in duodenal ulcer patients, but a 1:1 ratio was shown both in gastric and prepyloric/pyloric ulcer patients (p < 0.001). Patients with bleeding ulcers were significantly older than non-bleeders (68 years versus 58 years; p < 0001), as were patients with gastric ulcers compared with prepyloric/pyloric or duodenal ulcer patients (68 years versus 63 and 61 years, respectively; p < 0.01). The 10-year cumulative mortality in the unselected group (median age, 62 years) was 43%, and the annual risk of dying of peptic ulcer disease was 0.6%. No difference in 10-year recurrence rate was seen between patients with bleeding ulcer at inclusion and non-bleeders (46.2% versus 44.3%; p = NS), but the annual risk of bleeding was 5.3% and 0.8%, respectively (p < 0.0001). In the group of patients answering the questionnaire 51% reported upper abdominal pain during the last year of follow-up.

CONCLUSIONS

In spite of today's treatment regimens almost half of the patients with peptic ulcer disease experienced recurrence during a 10-year period, and more than half had ulcer symptoms after 10 years. Most probably, maintenance treatment with H2-receptor antagonists should have been offered more liberally during the 1980s.

Review article: Helicobacter pylori eradication--understandable caution but no excuse for inertia

The long-term management of patients with peptic ulcer disease is unsatisfactory, as judged by the persistently high levels of haemorrhage, perforation and death from this condition in Western countries. Although ulcer recurrence and complications can be prevented, many patients with peptic ulcer disease fail to receive the benefits of modern therapeutic regimens. In recent years, eradication of Helicobactor pylori has been promoted as a 'cure' for peptic ulcer disease and, while such claims are premature, there can be little doubt that this treatment--when successful--dramatically improves the medium-term prognosis of ulcer patients. However, in general, clinicians have given this promising therapeutic advance a lukewarm welcome. The aim of this detailed review of the literature is to remove the uncertainty and confusion surrounding many aspects of eradication therapy. Estimates are provided of the eradication rates after either triple therapy or the combination of omeprazole plus amoxycillin, and the sources of variation in published studies are discussed. Problems associated with eradication therapy, including side effects, compliance and re-infection, are addressed in order to ascertain the extent and clinical significance of each factor. In addition, studies reporting the outcome of patients with peptic ulcer disease after eradication are assessed with reference to both ulcer recurrence and complications. The result of the review is to dissipate much of the scepticism concerning eradication therapy. However, whilst acknowledging the efficacy of eradication therapy, its limitations have also to be recognized. By itself, it does not provide the complete answer to peptic ulcer disease. For some ulcer patients, eradication therapy is the preferred option; for others, prophylactic therapy with H2-receptor antagonists is more suitable. Guidelines are proposed for the selection of patients for each alternative therapy. The crucial point is that patients with peptic ulcer--excluding the small proportion with a mild form of the disease--require positive, long-term management consisting of either continuous prophylaxis with H2-receptor antagonists or the eradication of Helicobacter pylori.

Antisecretory effects of three omeprazole regimens for maintenance treatment in duodenal ulcer

This study was carried out to assess the antisecretory effects and their possible changes over time of three different dose regimens of omeprazole that could be proposed for maintenance treatment in duodenal ulcer. Forty-five patients with endoscopically proven duodenal ulcer were studied by means of 24-hr gastric pH-metry both in basal conditions and on the fifth day of acute treatment with omeprazole 20 mg in the morning. Ulcers healed after four weeks (in three cases after eight weeks) and afterwards, 15 patients were randomized to receive orally at 0800 hr in single-blind fashion omeprazole 10 mg daily (group A), 15 to receive omeprazole 40 mg on Saturday and Sunday followed by a five-day period without medication (group B), and 15 to receive omeprazole 20 mg every other day (group C) for up to three months. On the 20th and 80th days of these maintenance treatments 24-hr gastric pH-metry was repeated to assess the antisecretory effectiveness of each regimen over a two-month period. In patients of group B these tests began at 1700 hr on Friday, the last of five days off treatment, and in those of group C at 1700 hr of the day off medication. All three dose regimens of omeprazole were able to raise pH values significantly (P < 0.01-0.001) compared to basal levels. Omeprazole 20 mg every other day was more effective (P < 0.01) than omeprazole 40 mg weekend, but did not differ significantly from omeprazole 10 mg daily. The durations of acid inhibition (pH > 3.0 units/24 hr) were 12.44, 10.00, and 17.38 hr with groups A, B, and C, respectively. There was no significant difference between the pH profiles of the 20th and 80th days with every dose regimen. It is concluded that all three dose regimens of omeprazole are effective in reducing gastric acidity and their pharmacodynamic action does not change with time. Therefore they are suitable to be assessed in large clinical trials aimed at verifying the prevention of duodenal ulcer recurrence for longer periods.

Duodenal ulcer treatment: progress from pH to HP

The treatment of duodenal ulcer has evolved from ineffective medical treatments through an era of surgical management, back to increasingly effective medical treatment. The advent of H2-receptor antagonists changed the outlook for ulcer patients. More recently, Helicobacter pylori, an organism which inhabits gastric mucosa exclusively, has been implicated in the pathogenesis of peptic ulcer. This bacterium is found in the stomachs of around 95% of duodenal ulcer patients. Its eradication is shown dramatically to improve the rate at which ulcers relapse. The mechanisms whereby it may cause ulceration are not established--we review current hypotheses. No method of eradication is 100% effective, and many different dual or triple therapy regimens have been tried. Metronidazole resistance is reported but its importance is not yet known. Helicobacter eradication is likely to prove a cost-effective and acceptable treatment for duodenal ulcer, and once its value has gained acceptance widespread uptake of this option is anticipated.

Nizatidine as maintenance treatment of duodenal ulcer. Clinical results

In assessing treatments for chronic diseases such as duodenal ulcer (DU), measuring the patient's quality of life (QoL) is as important as objective measures of treatment efficacy. This study was part of a larger study assessing the QoL of patients with DU treated with nizatidine. The aim of this part of the 12-month study was to assess the clinical efficacy and the influence of maintenance therapy with nizatidine on the long-term treatment of patients with healed DU. The trial, which was open, randomized and controlled, was conducted in 177 centres throughout France. A total of 581 patients of 18 years or over with endoscopically confirmed DU were assigned to two groups. The active treatment group received nizatidine 150 mg/day for one year and the control group had no regular treatment. Both groups had free access to antacid tablets, use of which was recorded. Symptomatic relapse was treated with nizatidine 300 mg/day for 6 weeks. Clinical assessments were made every 2 months, at which times patients also recorded their symptoms. The relapse rate in the nizatidine-treated group was significantly lower than in the control group at 6 months (4.5% versus 15.3%; p < 0.0001). At 12 months the difference was still significant (8.0% versus 33.5%; p < 0.001). Antacid consumption was significantly greater in controls than in the nizatidine-treated group (44.7% versus 29.7%; p < 0.001). It is concluded that nizatidine is a safe and effective therapy for preventing DU recurrence in patients with endoscopically confirmed healed ulcers.

Trends in morbidity and mortality from peptic ulcer disease: Tayside versus Scotland

Recent studies have shown that the prophylactic use of H2-receptor antagonists reduces both ulcer recurrence and the risk of ulcer complications. Despite these results, epidemiological studies have failed to show any evidence of an effect of gastric anti-secretory drugs on complicated ulcer disease in the community. Since 1979, it has been the policy of the gastroenterology department at Ninewells Hospital in Tayside to recommend long-term, continuous therapy with H2-receptor antagonists for patients with peptic ulcer; in contrast, prophylactic therapy is less commonly used in the rest of Scotland. The difference in the management of peptic ulcer between Tayside and Scotland presented an opportunity to study the population effects of the widespread use of continuous H2-receptor antagonists on the morbidity and mortality from ulcer disease. This study compared the trends in hospital admissions, gastric surgery, haemorrhage, perforation and mortality from ulcer disease using data supplied by the Information and Statistics Division of the Common Services Agency, Scottish Health Service, Edinburgh. During the 1980s, hospital admissions for peptic ulcer declined significantly in Tayside, whereas in Scotland there was no obvious downward trend. Gastric surgery for ulcer disease declined throughout Scotland although the fall was significantly steeper in Tayside than in the rest of Scotland. For the population in general, the rate of perforation decreased faster in Tayside than in the rest of Scotland, although the difference was not significant. The rate of admissions for ulcer haemorrhage declined substantially in Tayside whereas there was little change in Scotland as a whole. The decrease in mortality from ulcer disease in all groups except younger females was more marked in Tayside than in Scotland, although the differences were not significant. The magnitude of the differences between Tayside and Scotland, and in particular the consistency of these results across a broad range of indicators of ulcer disease, suggests that the policy of prescribing long-term, continuous therapy with H2-receptor antagonists has reduced both uncomplicated and complicated peptic ulcer in the community in Tayside.

Gastric secretion and peptic ulceration in cirrhosis

Stomach function and secretions are altered significantly in patients with cirrhosis, both with or without portal hypertension. This review covers the abnormalities of gastric acid and pepsin secretion, and gastrin release. Histological and endoscopic changes, and the impaired cytoprotection associated with cirrhosis, are discussed in the context of abnormal gastric secretion. In addition, the symptomatology and association of H. pylori, and treatment of duodenal ulceration in cirrhosis are discussed. It is clear from this review that additional studies are needed to further understand gastric function in cirrhotic patients.

Prescribing policy for antiulcer treatment in the elderly

In the short and long term treatment of peptic ulcer in the elderly some problems have yet to be resolved, mainly concerning the physiology and pathophysiology of the aging stomach, the pharmacokinetic and pharmacodynamic properties of antiulcer drugs, and the presence of different risk factors compared with young patients. The available data from controlled trials of peptic ulcer in the general population and from the limited experience in geriatrics, show that the clinical efficacy and tolerability of the anti-secretory drugs (e.g. cimetidine, ranitidine and famotidine) and of cytoprotective compounds are similar to that observed in younger patients. However, more data are necessary concerning the optimal dosage in relation to physiological age-related changes of liver and kidney function, the duration of prophylactic treatment, and importantly, the assurance of adequate patient compliance.

A placebo-controlled investigation of duodenal ulcer recurrence after withdrawal of long-term treatment with ranitidine

Ninety-two patients with duodenal ulcer disease, who had received long-term continuous treatment with ranitidine for an average of 7.5 years, participated in a double-blind, placebo-controlled study to determine whether stopping ranitidine resulted in ulcer recurrence. Patients were randomized to continue with ranitidine (n = 46) or to receive placebo (n = 46) and were followed up for six months. Treatment failure was defined as the first symptomatic recurrence of ulcer. The occurrence of epigastric pain during the follow-up period was significantly less frequent in the ranitidine group (13%) than in the placebo group (43%) (P = 0.001). At six months, 9% of the ranitidine group had developed ulcer recurrence, compared with 48% in the placebo group (P < 0.001, logrank test). Multivariate analysis using the Cox proportional hazards model showed that younger age (P = 0.041) and a long history of ulcer disease (P = 0.025) were risk factors for ulcer recurrence but gender, smoking and duration or dose of previous ranitidine treatment were not predictive of relapse during treatment with placebo. In conclusion, withdrawal of ranitidine after more than five years of continuous treatment results in almost half of the patients developing symptomatic ulcer recurrence within six months. Thus, long-term continuous therapy does not alter the natural history of duodenal ulcer disease. Younger patients and those with a long history of ulcer disease appear to be at increased risk of developing ulcer recurrence if long-term treatment is withdrawn.

Gastroduodenal problems associated with non-steroidal, anti-inflammatory drugs (NSAIDs)

Non-steroidal, anti-inflammatory drugs (NSAIDs) inhibit gastric mucosal prostaglandins (PG) synthesis and thereby induce mucosal injury and ulceration, and possibly impair pain perception and ulcer healing. Dyspepsia is a poor guide to ulceration so a life threatening complication may be the first presentation and vigilance is important. Impaired healing can be overcome with more potent or prolonged ulcer healing therapy. For prophylaxis of high-risk patients (elderly women, past history, taking high doses, steroid co-therapy, first three months of treatment) the prescriber has to choose between the side effects of misoprostol or the more limited efficacy against gastric ulcers of ranitidine. Both drugs are highly effective in preventing duodenal ulcers.

Eradication of Helicobacter pylori and its effect in peptic ulcer disease

Since Helicobacter pylori was first cultured 10 years ago, there have been remarkable changes in our approach to the therapy of peptic ulcer disease. We now know that 90% of duodenal ulcer patients and 70% of all gastric ulcer patients are infected with H. pylori. Evidence is presented that the relapse rate of both duodenal and gastric ulcers can be substantially reduced if the bacterium is eradicated from the patient's stomach. Some of the anti-H. pylori eradication regimens currently available are discussed, with particular emphasis on the relative merits of standard triple therapy and an omeprazole/amoxycillin combination.

Ranitidine: differential effects on gastric bleeding and mucosal damage induced by aspirin

This study investigated the influence of ranitidine on mucosal injury and gastric bleeding in 20 normal volunteers taking 600 mg aspirin q.d.s. This study was a double-blind placebo controlled crossover study comparing ranitidine, as 150 mg b.d., 300 mg q.d.s. and 600 mg b.d. with placebo. Gastric mucosal injury was assessed at unsedated endoscopy by counting haemorrhagic and non-haemorrhagic erosions; bleeding was measured in gastric washings. Aspirin alone increased mucosal injury from 0 to 11.4 erosions (mean, P < 0.01) and bleeding from 1.77 to 9.11 microliters blood/10 min (mean P < 0.001). Ranitidine prophylaxis reduced bleeding to 5.34, 3.18 and 3.47 microliters/10 min with 150 mg b.d., 300 mg q.d.s. and 600 mg b.d. respectively (overall effect of ranitidine P < 0.001) and also reduced haemorrhagic erosions though it had no effect on the total number of erosions. Ranitidine is effective at reducing aspirin-induced gastric bleeding and whilst not reducing aspirin-induced gastric erosions, it does reduce the number that appear haemorrhagic. Ranitidine may have a role in the prophylaxis of aspirin-induced gastric bleeding.

Nine years of maintenance treatment with ranitidine for patients with duodenal ulcer disease

Four hundred and sixty-four patients with duodenal ulcer disease received continuous maintenance treatment with ranitidine for up to 9 years. Treatment failure was defined as either the first symptomatic recurrence of ulcer or the first ulcer recurrence accompanied by haemorrhage. Life tables were constructed using the Kaplan-Meier product-limit method; comparisons of survival curves were performed using the log-rank test; and multivariate analysis was carried out using the Cox proportional hazards model. Results. The proportion of patients remaining free from symptomatic recurrence of ulcer during maintenance treatment with either 150 mg/day or 300 mg/day ranitidine was: 95% at 1 year; 88% at 3 years; 86% at 5 years; and 81% at 7 and 9 years (95% C.I. 76-86%). Young age and the absence of exposure to non-steroidal anti-inflammatory drugs (NSAIDs) at the time of diagnosis of ulcer were shown to increase the likelihood of developing ulcer recurrence. The rate of ulcer recurrence after 9 years of maintenance treatment (17%) was significantly less than that after 5 years without active anti-ulcer therapy (80%), P = 0.0001. The proportion of patients who remained free from ulcer haemorrhage during maintenance treatment was: 99.1% at 1 year and 98.1% at 5 and 9 years (95% C.I. 96.7-99.6%). The risk of haemorrhage was significantly greater in patients who were not receiving active treatment (12.4% at 5 years) than in patients receiving maintenance treatment (less than 2% at 9 years), P = 0.0001 (log-rank test). Patients who had originally presented with haemorrhage had an increased risk of further ulcer bleeding compared with patients who presented with pain (P = 0.0013). A significantly greater proportion of patients with NSAID-associated duodenal ulcers remained free from ulcer recurrence during maintenance treatment compared with patients suffering from 'idiopathic' ulcers (P = 0.0238), although there was no difference between the two groups in respect of haemorrhage during maintenance treatment. Conclusions. (a) Continuous maintenance treatment with ranitidine for up to nine years successfully prevents ulcer recurrence in more than 80% of patients with duodenal ulcer disease. (b) Young age increases the risk of ulcer recurrence during maintenance treatment with ranitidine. Ulcers associated with NSAID-intake at the time of diagnosis have a lesser risk of recurrence during maintenance treatment. (c) The risk of haemorrhage in patients with ulcer disease receiving maintenance treatment with ranitidine for nine years was less than 2% compared with greater than 12% in untreated patients observed for 5 years.(ABSTRACT TRUNCATED AT 400 WORDS)