Comparison of ranitidine and high-dose antacid in the treatment of prepyloric or duodenal ulcer. A double-blind controlled trial

Pharmacologic Therapies in Gastrointestinal Diseases

Several key areas in gastroenterology pharmacotherapy are rapidly evolving, including the treatment of hepatitis C virus (HCV), irritable bowel syndrome, gastroesophageal reflux disease (GERD) and peptic ulcer disease. HCV treatment has radically changed in the past 2 years and now most patients are treatment candidates and have a high likelihood of permanent cure. Pharmacotherapy is now first-line treatment for patients with moderate to severe symptoms of irritable bowel syndrome. Proton pump inhibitors (PPIs) are the mainstay of therapy in gastric and duodenal ulcers and GERD, although long-term use carries the risk of several side effects that should be considered.

Is it really more difficult to treat prepyloric ulcers?

Prepyloric and duodenal ulcers have some common characteristics: gastric acid secretion is increased and there is an association with blood group O. Many, therefore, have considered prepyloric ulcers to be a variety of duodenal ulcer disease. From an anatomical point of view, however, prepyloric ulcers are clearly gastric ulcers. After proximal selective vagotomy, the recurrence rate is very high, amounting to more than 30% in 5 years; this is significantly higher than the rate for duodenal ulcers. Better results are obtained in prepyloric ulcers, if vagotomy is combined with a drainage procedure. In recent years, some evidence, primarily from Scandinavia, has accumulated indicating that prepyloric ulcers are more resistant to treatment with histamine H2-receptor antagonists than duodenal ulcers or ulcers located in other parts of the stomach. In addition, the recurrence rate is particularly high in prepyloric ulcers. One must, however, consider that not only have all of these studies included relatively small numbers of patients, but also the prepyloric ulcer healing rates in other studies were similar to those observed for both duodenal ulcers and ulcers located elsewhere in the stomach. Prospective studies with large numbers of patients are, therefore, necessary before a clear-cut conclusion can be reached. There are several reasons why prepyloric ulcers could be more resistant to treatment. Impaired gastric emptying, duodeno-gastric reflux or chronic gastritis, especially in conjunction with Campylobacter pylori infection, must be considered. At present, one can only speculate on the validity of any of these hypotheses.

Antacid talcid activates in gastric mucosa genes encoding for EGF and its receptor. The molecular basis for its ulcer healing action

In previous studies [Gut 35 (1994) 896-904], we demonstrated that antacid talcid (TAL) accelerates gastric ulcer healing and provides better quality of mucosal restoration within the scar than the omeprazole (OME). However, the mechanisms of TAL-induced ulcer healing are not clear. Since growth factors promote cell proliferation, re-epithelization, angiogenesis and ulcer healing, we studied whether TAL and/or OME affect expression of epidermal growth factor (EGF) and its receptors (EGF-R) in both normal and ulcerated gastric mucosae. Rats with or without acetic acid-induced gastric ulcers (n = 64) received i.g. twice daily 1 mL of either: A) placebo (PLA); B) TAL 100 mg; or C) OME 50 mg x kg(-1) for 14 d. Studies of gastric specimens: 1) ulcer size; 2) quantitative histology; 3) expression of EGF mRNAs was determined by RT/PCR; 4) gastric sections were immunostained with antibodies against EGF and its receptors. In non-ulcerated gastric mucosa of placebo or omeprazole treated group, EGF expression was minimal, while EGF-R was localized to few cells in the mucosal proliferative zone. Gastric ulceration triggered overexpression of EGF and its receptor in epithelial cells of the ulcer margin and scar. In ulcerated gastric mucosa TAL treatment significantly enhanced (versus PLA and omeprazole) expression of EGF and EGF-R. OME treatment reduced expression of EGF in ulcerated mucosa by 55 +/- 2% (P < 0.01). It is concluded that: 1) treatment with TAL activates genes for EGF and its receptor in normal and ulcerated gastric mucosae; 2) since EGF promotes growth of epithelial cells and their proliferation and migration, the above actions of TAL provide the mechanism for its ulcer healing action and improved (versus OME) quality of mucosal restoration.

Antacids revisited: a review of their clinical pharmacology and recommended therapeutic use

Antacids are commonly used self-prescribed medications. They consist of calcium carbonate and magnesium and aluminum salts in various compounds or combinations. The effect of antacids on the stomach is due to partial neutralisation of gastric hydrochloric acid and inhibition of the proteolytic enzyme, pepsin. Each cation salt has its own pharmacological characteristics that are important for determination of which product can be used for certain indications. Antacids have been used for duodenal and gastric ulcers, stress gastritis, gastro-oesophageal reflux disease, pancreatic insufficiency, non-ulcer dyspepsia, bile acid mediated diarrhoea, biliary reflux, constipation, osteoporosis, urinary alkalinisation and chronic renal failure as a dietary phosphate binder. The development of histamine H2-receptor antagonists and proton pump inhibitors has significantly reduced usage for duodenal and gastric ulcers and gastro-oesophageal reflux disease. However, antacids can still be useful for stress gastritis and non-ulcer dyspepsia. The recent release of proprietary H2 antagonists has likely further reduced antacid use for non-ulcer dyspepsia. Other indications are still valid but represent minor uses. Antacid drug interactions are well noted, but can be avoided by rescheduling medication administration times. This can be inconvenient and discourage compliance with other medications. All antacids can produce drug interactions by changing gastric pH, thus altering drug dissolution of dosage forms, reduction of gastric acid hydrolysis of drugs, or alter drug elimination by changing urinary pH. Most antacids, except sodium bicarbonate, may decrease drug absorption by adsorption or chelation of other drugs. Most adverse effects from antacids are minor with periodic use of small amounts. However, when large doses are taken for long periods of time, significant adverse effects may occur especially patients with underlying diseases such as chronic renal failure. These adverse effects can be reduced by monitoring of electrolyte status and avoiding aluminum-containing antacids to bind dietary phosphate in chronic renal failure. Antacids, although effective for discussed indications of duodenal and gastric ulcer and gastro-oesophageal reflux disease, have been replaced by newer, more effective agents that are more palatable to patients. Antacids are likely to continue to be used for non-ulcer dyspepsia, minor episodes of heartburn (gastro-oesophageal reflux disease) and other clear indications. Although their wide-spread use may decline, these drugs will still be used, and clinicians should be aware of their potential drug interactions and adverse effects.

Policy analysis of the conversion of histamine2 antagonists to over-the-counter use

OBJECTIVES

The authors assess the costs associated with treatment of dyspepsia with histamine2 antagonists versus without availability of over-the-counter (OTC).

METHODS

A cost analysis was performed using a decision-analysis model. Patients with an initial episode of dyspepsia were studied. The model includes costs associated with consumption of OTC and prescription (Rx) medications for dyspepsia, physician visits and associated diagnostic testing, time spent for physician visits and diagnostic tests, and hospitalization costs.

RESULTS

The model is sensitive to the relative cost of histamine2 antagonists when purchased Rx or OTC, as well as to the efficacy of these drugs in relieving dyspeptic symptoms. For patients with nonulcer dyspepsia (the largest group of likely consumers), the model demonstrates a cost savings if the OTC cost of the medication is slightly less than one third the Rx cost. Costs are similar whether or not histamine2 antagonists are available OTC. If the symptom relief efficacies of histamine2 antagonists are equivalent whether purchased by prescription only or OTC, then the health-care expenditures for a typical patient with dyspepsia are $204 for OTC availability and $203 for Rx-only use. Viewing costs from the perspective of a managed-care organization, expenditures for an episode of dyspepsia are $149 regardless of whether or not histamine2 antagonists are available OTC. Restricting the analysis to patients with underlying nonulcer dyspepsia yields similar results. Variation of numerous assumptions and probabilities other than histamine antagonist cost and efficacy, including costs associated with physician visits and diagnostic tests, and the likelihood of seeking medical care, do not substantially affect the results of the model.

CONCLUSIONS

Health-care costs associated with initial treatment of dyspepsia are similar regardless of the availability of histamine2 antagonists OTC. This is due largely to the similar efficacy of these drugs compared with antacids and the predicted increase in diagnostic testing that may result if a patient visits a physician after failure to achieve symptom relief with OTC use of histamine2 antagonists.

The randomized controlled clinical trial in gastroenterology: the Danish contributions from 1970 to 1994

More than 200 Danish randomized controlled clinical trials in gastroenterology published from 1970 to 1994 were retrieved by electronic media, by hand-searching relevant journals, and by direct requests to Danish gastroenterologists. With the historical perspective through a quarter of a century, these papers are outlined to provide a survey of the pieces of information that Danish gastroenterologists have contributed to the present knowledge of therapeutics. The presented randomized controlled clinical trials constitute an impressive sum of knowledge within a diversity of topics. A cautious analysis of the time pattern for the publications in addition to the contents of the reports discloses that the discipline of planning and executing relevant controlled clinical trials is now in blossom in Danish gastroenterology.

Antacids. Indications and limitations

Antacids have served us well for over a century. In terms of peptic ulcer disease, the attitude in the late 1950s to 1970s that antacids should be taken only on demand was unjustified and erroneous. 13 recent endoscopic controlled studies have confirmed the efficacy of antacids in the healing of duodenal ulcer, achieving about 75% healing in 4 weeks. The efficacy of antacids in promoting gastric ulcer healing has been less well studied and the results are controversial. The most appropriate and economical antacid regimens for the treatment of duodenal ulcer disease should include tablets or liquid that have acid neutralising capacity of 400 mmol/day given at least an hour after meals. As a long term therapy, antacids appear to work, but need be taken in multiple daily doses, a regimen which is unlikely to meet with long term patient compliance. Patients with gastro-oesophageal reflux disorders or pregnancy-related reflux have also benefited from the usage of antacids ad libitum. Early previous studies have clearly demonstrated the efficacy of antacids in reducing gastro-oesophageal reflux and healing of reflux oesophagitis. The acidity of the gastric contents is the major determining factor in the outcome of the aspiration pneumonitis occurring during delivery. The prophylactic use of antacids during delivery has helped to reduce the severity of this complication. Similarly, the prophylactic administration of antacid aiming to maintain gastric pH between 3.5 to 7.0 has resulted in significant reduction of bleeding due to stress associated ulcers and/or erosive haemorrhagic gastritis in critically ill patients. Antacid therapy, however, is controversial in the management of nonulcer dyspepsia or nonsteroidal anti-inflammatory drug related upper gastrointestinal mucosal damage. Undoubtedly, antacids have major roles to play in the treatment of gastric acid related disorders. They have clear advantages and disadvantages when compared with the antisecretory agents. New proton pump inhibitors in particular have certainly superseded antacids and even the H2-receptor antagonists in many respects. However, the long term safety record of antacids remains unsurpassed by any of the new antisecretory agents.

Circadian acidity pattern in prepyloric ulcers: a comparison with normal subjects and duodenal ulcer patients

We used continuous 24-h pH monitoring to compare the circadian intragastric acidity of 36 patients with prepyloric ulcers (PPU) with that of 101 normal subjects (NS) and that of 206 patients with duodenal ulcer (DU). The ulcer crater was endoscopically ascertained in all cases, and PPU were located within an area up to 2 cm proximal to the pylorus. The pH curve pertaining to DU patients ran below that of NS during most of the circadian period, whereas the pH profile of PPU patients was higher than that of NS, and this was particularly true during the evening and the night. The acidity of PPU patients was significantly lower (p < 0.01) than that of NS during the night only, whereas it was lower (p < 0.05-0.001) than that of DU patients during each time interval analysed (24 h, nighttime, and daytime). Our findings show that the gastric acidity of PPU patients differs greatly from that of DU patients, since it is lower throughout the whole 24-h period, and particularly during the night. Thus these two entities are pathophysiologically different with regard to the acidity pattern and should be considered two distinct subgroups of peptic ulcer disease instead of being incorporated, as usually happens, in the clinical group 'duodenal ulcer disease'.

Antacids and ulcer healing. A review of the evidence

There have been a number of controlled trials of antacids in the treatment of patients with peptic ulcer disease. As a general rule the size of studies has been small and there have been difficulties ensuring adequate binding, because of the formulation and taste of the antacids. Despite these difficulties, antacids appear to be effective ulcer healing agents with efficacies resembling those of other antiulcer drugs. Definite dose relationships are unclear but high doses of buffering capacity over 200 mmol/day appear unnecessary and are associated with increasingly frequent adverse effects. Low dose maintenance treatment is effective at limiting duodenal ulcer relapse.

Ranitidine in the treatment of duodenal ulcer disease: relationship between antisecretory effect and ulcer healing rate

The relationship between drug-induced suppression of intragastric acidity and the rate of duodenal ulcer healing was examined using data for a single drug, ranitidine, from 156 clinical trials involving 16,362 patients together with data on acid suppression from 37 studies of intragastric acidity in 630 subjects. In these studies ranitidine was given in doses ranging from 150 mg to 1200 mg per day administered in 9 different dosage regimens. The overall percentage of patients whose duodenal ulcers healed at 2 and 4 weeks on the different regimens was highly correlated with the percentage suppression of 24-hour intragastric acidity induced by different regimens. Thus the therapeutic benefit of a given ranitidine dosage regimen in healing duodenal ulcers relates directly to its antisecretory effect.

Omeprazole 20 mg three days a week and 10 mg daily in prevention of duodenal ulcer relapse. Double-blind comparative trial

In a double-blind, parallel-group clinical trial of 195 patients with duodenal ulcers who after a short-term study had relief of pain and healed ulcers proved endoscopically, 65 were randomized to receive 20 mg omeprazole 3 days a week (once in the morning from Friday to Sunday), 64 to receive 10 mg omeprazole once daily in the morning, and 66 to receive placebo for up to 6 months. The patients underwent repeat endoscopy with biopsy of the gastric fundic mucosa (qualitative assessment of argyrophilic cell population), assessment of symptoms, and laboratory screening with measurement of basal serum gastrin concentrations at 3 and 6 months or more often if indicated by recurrence of symptoms. At 3 months, endoscopically proved ulcer relapse occurred in 16% receiving 20 mg omeprazole 3 days a week; 21% receiving 10 mg omeprazole daily; and 50% receiving placebo. At 6 months, corresponding rates were 23%, 27%, and 67% with 95% confidence intervals of difference between the placebo group and omeprazole groups of 28%-60% and 24%-56% (P less than 0.00001), respectively, and between omeprazole groups of -19%-11% (NS). No major clinical or laboratory side effects were noted. Thus both omeprazole regimens are effective and safe in preventing duodenal ulcer relapse.

Gastric emptying of two radiolabelled antacids

The rate of gastric emptying of two antacids, magaldrate and Maalox, was investigated using scintigraphy. Successful labelling of the antacids was carried out with 99mTc. The stability of the 99mTc-labelled antacids was satisfactory and there was no difference in antacid capacity between the labelled and unlabelled antacids. The studies were carried out on 15 healthy male volunteers. After an eight hour fast each subject ingested a standardised meal of 95.7 MJ (400 kcal). One hour later 10 ml of one of the two antacids previously labelled with 99mTc was administered. Serial detection by anterior and posterior projection of the amount of antacid retained in the stomach was performed to determine gastric emptying of antacid. One week later the study was repeated under the same conditions with the other antacid also labelled with 99mTc. The mean (SD) percentages of antacid retained in the stomach fit a linear model with a t1/2 of 86.6 (15.3) minutes for magaldrate and 52.3 (5.2) minutes for Maalox (p less than 0.01). When the mean percentages of retention at six time intervals were compared for both antacids, it was found that Maalox emptied much faster (p less than 0.01 at 15 and 30 minutes, p less than 0.02 at 45, 60, 75, and 90 minutes).

Healing of chronic gastroduodenal ulcerations by antacids. Role of prostaglandins and epidermal growth factor

Antacids show gastroprotective action against various irritants in experimental animals and enhance the healing of chronic gastroduodenal ulcers in humans but the mechanisms of these effects are unknown. The present study was designed to determine whether prostaglandin (PG) and epidermal growth factor (EGF), which also have protective and antiulcer properties, contribute to the action of antacids on rat's stomach. It was found that Maalox 70 and its active component, Al(OH)3, enhance significantly the healing of chronic gastric and duodenal ulcers observed during 7 and 14 days after their induction. Pretreatment with indomethacin caused a significant prolongation of ulcer healing, and this was accompanied by a significant reduction in PG and EGF formation, suggesting that both factors may be involved in ulcer healing. Maalox and Al(OH)3 failed to prevent the suppression of PG by indomethacin but were equally effective in ulcer healing in rats without and with indomethacin administration, suggesting that endogenous PG may not play any important role in the healing process by these drugs. Removal of salivary glands, the major source of EGF, also prolonged ulcer healing but, again, Maalox was as effective in ulcer healing as in rats with intact salivary glands. Our findings that Maalox at pH above 3.0 binds significant amounts of EGF, enhances the binding of EGF to the ulcer area, and stimulates mucosal growth, suggest that EGF may be involved in ulcer healing; however, because antacids are also effective after sialoadenectomy, EGF does not seem to be the major factor in ulcer healing by these drugs.

Antacids for duodenal ulcer: current role

Recent years have witnessed significant progress in antacid therapy of duodenal ulcer disease, consisting in the demonstration that the doses required for ulcer healing are much smaller and less frequent that those regarded as necessary or optimal in the past. Antacids at these dosages proved to be as effective as H2-blockers both in terms of healing capacity and in relieving ulcer symptoms and are associated with negligible gastrointestinal side-effects. In addition, there has been a renewed interest in the tablet formulation, which now appears more acceptable to the patient. All these characteristics make antacids competitive with other anti-ulcer agents, especially in terms of the cost/benefit ratio.

Gastroprotection by an aluminium- and magnesium hydroxide-containing antacid in rats. Role of endogenous prostanoids

This study was designed to determine the gastroprotective actions of an antacid (Maalox 70) and its components, Al(OH)3 and Mg(OH)2, against acute gastric lesions induced by absolute ethanol, acidified aspirin (ASA), and water immersion and restraint stress in rats. Given orally, the antacid prevented dose-dependently the formation of gastric lesions by all three ulcerogens, and these effects were similar to those obtained with a methylated prostaglandin E2 (PGE2) analog. Active Al(OH)3 gel was equipotent with Maalox, whereas Mg(OH)2 was significantly less effective in gastroprotection than Maalox 70. Chemically inactive Al(OH)3 wet gel showed only small and insignificant protective properties. Since the gastroprotective activities of Maalox 70 against ethanol lesions cannot be reversed by pretreatment with indomethacin, and since neither Maalox 70 nor its active components affected the mucosal generation of PGE2 and leukotriene C4, we postulate that mucosal prostanoids are not the primary mediators in the mechanism of their protective action on the gastric mucosa.

A comparison of low-dose maintenance treatment with enprostil against ranitidine in the prevention of duodenal ulcer recurrence

Enprostil, a prostaglandin E2 analogue, is effective in healing acute duodenal ulcer but its value in preventing recurrence, when given daily for maintenance therapy, is uncertain. In this three-centre study we compared enprostil and ranitidine maintenance therapy; the latter is known to reduce duodenal ulcer relapse rates. Patients whose duodenal ulcers had been healed by treatment with an H2-receptor antagonist were randomized to receive single-blind treatment with either 35 micrograms enprostil (n = 64) or 150 mg ranitidine (n = 64) at bedtime for periods of up to 1 year. Endoscopy was routinely performed at 3 months at one centre, and at 6 and 12 months at all three centres, or whenever ulcer symptoms recurred. Clinical assessment and laboratory investigations were performed every 3 months. Relapse, defined as recurrent ulcer with or without pain, or erosions with pain, was significantly greater in patients on enprostil, the comparative rates at 3, 6 and 12 months were: enprostil 23, 31 and 36% ranitidine 6, 12 and 17% (P = 0.013; P = 0.03 and P = 0.03, respectively). Thirty-one patients reported adverse events, the most common being headache (enprostil = 6, ranitidine = 2) and mild diarrhoea (enprostil = 6, ranitidine = 0). Four patients on enprostil were withdrawn for adverse events, although none terminated because of diarrhoea. There were no clinically significant changes in haematology or biochemistry. Enprostil may reduce duodenal ulcer relapse but at a dose of 35 micrograms nightly, it is less effective than 150 mg ranitidine nightly.

Reducing meal-stimulated acid secretion versus reducing nocturnal acid secretion for healing of duodenal ulcer

Both meal-stimulated and nocturnal acid secretions have been shown to be abnormally increased in patients with duodenal ulcer. The relative efficacy of an acid-reducing regimen aimed specifically at controlling postprandial acid secretion compared with one that controls nocturnal acid secretion is, however, not known. The endoscopic healing rates at weeks 2, 4, 6, 8, 10, and 12 of three cimetidine regimens with identical total daily dose--bedtime (1200 mg), mealtime (400 mg three times a day with meals), and reference (200 mg three times a day with meals and 600 mg at bedtime)--were compared in a randomized study on 141 patients with endoscopically proven duodenal ulcer. Evaluating endoscopists were blinded to patients' form and duration of treatment and their clinical progress; patients were unaware of the comparative design of the study. Life-table analysis for the 12 weeks of observation revealed that the mealtime regimen resulted in significantly (P less than 0.05) better healing rates than either the bedtime or the reference regimen. The differences were accounted for largely by the significantly (P less than 0.04) better healing rate at two weeks with the mealtime regimen (68%) than with either the bedtime (47%) or the reference (45%) regimen. These findings indicate that a regimen that aims at controlling meal-stimulated acid secretion achieves a faster healing rate than one that aims at controlling nocturnal acid secretion in the treatment of duodenal ulcer, and they suggest that postprandial acid secretion plays a greater role than nocturnal acid secretion in the pathophysiology of this condition.

Relapse of gastric ulcers after healing with omeprazole and cimetidine. A double-blind follow-up study. Danish Omeprazole Study Group

Two hundred and seventeen gastric ulcer patients whose ulcers had healed during omeprazole (30 mg) or cimetidine (1 g) treatment entered a follow-up study for 6 months. Endoscopy was performed after 6 months, or earlier if the patient had a symptomatic relapse. Both the initial treatment and the follow-up study were double-blind. Ulcers recurred in 35% of the omeprazole-treated patients and in 41% of the cimetidine-treated patients (p greater than 0.05; log-rank test). The recurrence rate was 45% among smokers, compared with 25% among non-smokers (p less than 0.05). Ulcers also recurred more rapidly (p less than 0.05) in patients with a healed prepyloric ulcer (49%) than in patients with a healed corpus ulcer (23%).

Ranitidine. An updated review of its pharmacodynamic and pharmacokinetic properties and therapeutic use in peptic ulcer disease and other allied diseases

Ranitidine, a histamine H2-receptor antagonist, is now well established as a potent inhibitor of gastric acid secretion effective in the treatment and prophylaxis of gastrointestinal lesions aggravated by gastric acid secretion. Therapeutic trials involving several thousands of patients with peptic ulcer disease confirm that ranitidine 300mg daily administered orally in single or divided doses is at least as effective as cimetidine 800 to 1000mg daily in increasing the rate of healing of duodenal and gastric ulcers. Similar dosages of ranitidine have been shown to relieve the symptoms of reflux oesophagitis and heal or prevent gastrointestinal damage caused by ulcerogenic drugs. Ranitidine 150mg orally at night maintains ulcer healing in the long term. Ranitidine has also demonstrated good results in the treatment of Zollinger-Ellison syndrome and in the prevention of aspiration pneumonitis when given prior to surgery and to pregnant women at full term. It may also have a place in the management of acute upper gastrointestinal bleeding and in the prevention of stress ulcers in the intensive care setting, although these areas require further investigation. Ranitidine has been used safely in obstetric patients during labour, in children, the elderly, and in patients with renal impairment when given in appropriate dosages. The drug is very well tolerated and is only infrequently associated with serious adverse reactions or clinically significant drug interactions. Even at high dosages, ranitidine appears devoid of antiandrogenic effects. Ranitidine is clearly comparable or superior to most other antiulcer agents in the treatment and prevention of a variety of gastrointestinal disorders associated with gastric acid secretion. With its favourable efficacy and tolerability profiles, ranitidine must be considered a first-line agent when suppression of gastric acid secretion is indicated.

Rioprostil and ranitidine in the treatment of prepyloric gastric ulcer. A double-blind comparative trial

Rioprostil, a synthetic 16-methylprostaglandin E1, combines antisecretory with cytoprotective properties, the latter being active even at doses below those required for acid inhibition. To test whether rioprostil given in antisecretory doses would heal prepyloric ulcers rapidly, we assigned patients with endoscopically proved ulcers randomly to double-blind treatment with 100 micrograms rioprostil twice daily or 150 mg ranitidine twice daily for up to 8 weeks. Recruitment was terminated at the time point of planned interim analysis because the total healing rate was markedly lower than expected. Thirty patients were allocated to each treatment group. The cumulative healing rates at 4 and 8 weeks were 40% and 60%, respectively, in the rioprostil group versus 70% and 90%, respectively, in the ranitidine group (p less than 0.01). Pain relief occurred simultaneously in the two groups. No major adverse effects were noted. These findings question the clinical relevance of using 'cytoprotection' by prostaglandin analogues as treatment for prepyloric ulcer disease in the short term.

Effect of 10 mg and 20 mg omeprazole daily on duodenal ulcer: double-blind comparative trial

One-hundred and seventy-one patients with endoscopically proven duodenal ulcers were allocated at random to double-blind treatment with 10 or 20 mg of omeprazole in the morning for up to 4 weeks. Patients completed the study if ulcer healing and pain relief had occurred at 2 weeks. A total of 155 patients completed the trial. Patients treated with 20 mg of omeprazole daily responded significantly more rapidly than those treated with 10 mg of omeprazole daily (P less than 0.001; Cochran-Mantel-Haenszel test covering both time points), cumulative healing rates at 2 and 4 weeks were 74% (58/78) and 91% (71/78), respectively. The corresponding rates in the group treated with 10 mg daily were 48% (39/81) and 75% (58/77). Pain relief was again more pronounced during treatment with the larger dose (P less than 0.05; stratified Wilcoxon test). No major clinical or biochemical side effects were noted. An omeprazole dose of 20 mg daily is preferable to a lower dose for the treatment of duodenal ulcer disease in the short term.

Omeprazole in the treatment of prepyloric ulcer: review of the results of the Danish Omeprazole Study Group

A Danish multicentre trial assessed the value of the more effective gastric acid inhibition provided by omeprazole, as compared with cimetidine, in promoting ulcer healing and pain relief in patients with prepyloric ulcers. A total of 176 patients were randomly allocated to 6 weeks of treatment with either cimetidine, 200 mg t.d.s. and 400 mg at bedtime, or omeprazole, 30 mg once daily. At 2, 4, and 6 weeks after entry, ulcers healed in a larger proportion of patients treated with omeprazole (54%, 81% and 86%) than in those treated with cimetidine (39%, 73% and 78%) ('intention-to-treat' cohort; p less than 0.05 at 2 weeks using Cochran-Mantel-Haenszel test). A higher proportion of patients on omeprazole became free of pain during the first week of treatment (p less than 0.05). No major clinical or biochemical side-effects were noted. A 6-month follow-up study revealed no significant difference between the recurrence rates after omeprazole or after cimetidine treatment.

Gastric adenocarcinoma masquerading endoscopically as benign gastric ulcer. A five-year experience

The pathologic features and five-year survival of patients in whom gastric cancer masquerades at endoscopy as a benign gastric ulcer has been poorly characterized. We reviewed retrospectively all cases of gastric adenocarcinoma in three hospitals for a five-year period. Of 266 patients with gastric adenocarcinoma, 169 (63.5%) had endoscopy with biopsy prior to diagnosis of cancer. In 159 of these 169 patients (94.1%), the endoscopic findings suggested cancer, while in the remaining 10 patients (5.9%) the endoscopic appearance suggested benign ulcer. In six of these 10 patients, the initial endoscopic biopsies did not reveal cancer and correct diagnosis was delayed for as long as 14 months. Three of the 10 patients had "early gastric cancer" by pathologic criteria at gastrectomy, although one had lymph node metastasis. The other seven patients had pathologic criteria for advanced gastric cancer, and three had lymph node metastasis. In spite of advanced cancer and/or lymph node metastasis in eight of our 10 patients, five-year survival in these patients with benign-appearing ulcers was 70%, as compared to 17% in patients whose gastric lesions appeared malignant at endoscopy.

Antacids: the past, the present, and the future

Antacids have served us well for over a century. The attitude in the late 1950s to 1970s that antacids should be taken only on demand was unjustified and was based on what can be seen nowadays as misinterpretation of scientific data. Twelve recent endoscopic controlled studies have confirmed the efficacy of antacids in the healing of duodenal ulcer, achieving about 75% healing in 4 weeks. Like H2-receptor antagonists, the efficacy of antacids in the healing of gastric ulcers is controversial, most probably related to the even greater pathogenetic heterogeneity of this condition. Antacids should be given at least four times a day and at least 1 hour after meals, since their therapeutic success most likely depends on neutralization of postprandial acid secretion. In vivo, the newer tablet forms are indistinguishable from the liquid forms in terms of neutralizing efficiency and healing efficacy. The ideal dose is one that neutralizes 400 mmol of acid. Combination with an anticholinergic drug is effective and a recent report suggests that this may lead to longer remission than with H2-receptor antagonists. As a long-term therapy, antacids appear to work but need to be taken in multiple daily doses, a regimen which is unlikely to meet with long-term patient compliance. The success of antacids in duodenal ulcer healing should alert us to the importance of controlling the meal-stimulated acid secretion in ulcer therapy, and to the hard fact that acid is a non-permissive factor in ulcer healing.

Are endoscopic and/or histologic findings in gastroduodenal mucosa a predictor of clinical outcome in peptic ulcer disease? A 1-year follow-up study after initial healing with either cimetidine or medium-dose antacid

Patients with duodenal ulcer (DU; n = 79) or prepyloric ulcer (PPU; n = 39) received cimetidine, 400 mg twice daily, or Novaluzid, 10 ml four times daily (acid-neutralizing capacity, 340 mmol/day), in a multicentre, randomized, double-blind trial. Ulcer healing was almost identical with the two treatments at 4, 6, and 12 weeks in the DU group. Cimetidine was significantly more effective than antacids in alleviating symptoms in PPU disease, with no significant difference in ulcer healing. In the PPU group the symptomatic improvement was inferior irrespective of treatment, and there was a significantly lower healing rate at 4 weeks (p less than 0.05) than in the DU group. The relapse rate over a 1-year follow-up period with no therapy did not differ between the two treatment groups or between the two ulcer groups. No factors in history of disease or endoscopic or histologic variables were of predictive value with regard to delayed healing. The macroscopic appearance of the duodenal and antral mucosae improved significantly when ulcers had healed. In the subgroup of about 50% DU patients who experienced a relapse during the 1-year follow-up period, the histologic scoring of duodenitis remained basically unchanged, contrary to the significant improvement seen in the non-relapsing subgroup. The microscopic changes of the antral mucosa from the time of inclusion to healing seen in the PPU patients were of no predictive value with regard to relapse rate.

Risk factors for healing of duodenal ulcer under antacid treatment: do ulcer patients need individual treatment?

In order to identify the risk factors affecting the healing of duodenal ulcer, a clinical trial with effective dose of antacid was carried out in 53 patients. Duration of ulcer history, number of relapses, duration of the last and present relapse, number, duration and severity of pain attacks in the present ulcer relapse, pain radiation to back, vomiting, appetite, smoking habit, intake of analgesics and previous haemorrhage were registered. Number of ulcers, ulcer depth, bublar narrowing, erosions, duodenitis at initial endoscopy and healing of ulcer were assessed by one endoscopist. Basic and peak acid output were measured. The extent of duodenitis on the site opposite the ulcer was determined by histological examination. Sixty per cent of the duodenal ulcers were healed after three weeks. By univariate analysis, the following factors affect the healing; pain radiation to back and pain duration during treatment (p less than 0.001), multiple or deep ulcers, narrowing of duodenal bulb (p less than 0.01), number of pain attacks and poor appetite (p less than 0.05). By the stepwise logistic regression model, the following factors were selected as predictors for healing of duodenal ulcer with 76% correct classification: pain radiation to back (p = 0.002), deep ulcer (p = 0.013), multiple ulcers (p = 0.028). Number of cigarettes/day (p less than 0.007) and male sex (p = 0.036). By this model, the prediction of healing could be accurately assessed in 78% in a new sample. Individual treatment should be carried out on the basis of these factors.

Effect of omeprazole and cimetidine on prepyloric gastric ulcer: double blind comparative trial

We conducted a six week double blind randomised study of 176 patients with prepyloric gastric ulcer to determine whether the proton pump inhibitor, omeprazole 30 mg daily would accelerate healing and pain relief, as compared with cimetidine 1 g daily. At two, four, and six weeks after entry ulcers healed in a larger percentage of patients treated with omeprazole (54, 81, and 86%) than of those treated with cimetidine (39, 73, and 78%) ('intention to treat' cohort; p less than 0.05 at two weeks). A higher proportion of patients on omeprazole became free of pain during the first week of treatment (p less than 0.05). No major clinical or biochemical side effects were noted. Omeprazole is an efficient treatment for patients with prepyloric gastric ulcers.

Safety perspectives on parenteral H2-receptor antagonists

Much controversy has been associated with the similarities and differences among the histamine (H2)-receptor antagonists with respect to safety. The safety issues, including those recently identified with the use of parenteral H2-receptor antagonists, are analyzed here with the intent of placing these data into proper perspective. The focus of the analysis is on a few of the more important issues: central nervous system effects and clinically significant drug interactions. A review of the voluminous safety literature on these agents indicates that, as a class, they have enviable safety records. When individual agents are compared, some small differences in safety profiles emerge, but, on the whole, similarities are more striking.

Medical care of the surgical patient with gastrointestinal disease

Common perioperative gastrointestinal disorders of surgical patients are presented. Recommendations for appropriate medical evaluation and management are described.

Enprostil and ranitidine in prevention of duodenal ulcer relapse: one year double blind comparative trial

One hundred and forty two patients with duodenal ulcer who after a short term study had relief of pain and healed ulcers proved endoscopically were allocated at random to double blind maintenance treatment with enprostil (a synthetic dehydroprostaglandin E2) 35 micrograms or ranitidine 150 mg at bedtime for up to 12 months. Patients were monitored every third month and examined by endoscopy at three, six, and 12 months, or more often if warranted. The cumulative relapse rates in the enprostil group at three, six, and 12 months were 37% (25/67), 56% (37/66), and 62% (41/66), respectively. The corresponding rates in the ranitidine group were 8% (6/71), 19% (13/69), and 29% (20/69). These differences were highly significant and further enhanced by life table analysis adjusting for withdrawals and by an "intention to treat" analysis in which absence of proof of non-recurrence was counted as failure, more patients in the enprostil group having been withdrawn because of adverse events or recorded as non-compliant with the protocol. Enprostil 35 micrograms at bedtime cannot be recommended for preventing relapse of duodenal ulcer. Furthermore, the results challenge the clinical relevance of using so called "cytoprotection" for preventing recurrence.

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.

It is wise to prescribe NSAIDs with modern gastroprotective agents?

The administration of non-steroidal anti-inflammatory drugs (NSAIDs) leads to mucosal lesions in the upper gastrointestinal tract. Furthermore, NSAIDs increase the risk of ulcer bleeding and perforation, but the overall risk of fatal complications is relatively small (about 21 per one million prescriptions). Therefore, in asymptomatic patients, it is not justified to prescribe NSAIDs together with gastroprotective agents. The following recommendations can be given with respect to the management of peptic lesions in patients taking NSAIDs: (i) Fibre endoscopy should be performed even when there are relatively mild symptoms since mucosal lesions in rheumatic patients under NSAIDs produce minor or no symptoms. (ii) "Modern" NSAIDs might produce less gastric lesions than aspirin. (iii) Rheumatic patients with peptic disorders should be treated with an H2-antagonist. (iv) After complications such as ulcer bleeding or after rapid recurrence of peptic lesions, maintenance treatment with an H2-antagonist is advisable.

Duodenal, prepyloric, and combined duodenal/prepyloric ulcer disease: three distinct entities of juxtapyloric ulcer disease?

One hundred and seven patients with long-standing and severe chronic juxtapyloric ulcer disease were classified in accordance with the location of the present ulcer and previous ulcers into 1) pure duodenal (DU), 2) pure prepyloric (PU), and 3) combined duodenal/prepyloric (DU/PU) or prepyloric/duodenal (PU/DU) ulcer disease. In a prospective follow-up study over a 3-year period after parietal cell vagotomy (n = 39) or during continuous treatment with cimetidine (n = 62) patients with DU had recurrent ulcers located exclusively to the duodenal bulb and patients with PU, exclusively to the prepyloric region. In patients with DU/PU and PU/DU recurrent ulcers occurred on either side of the pylorus. Basal acid and basal pepsin outputs were higher and bile acid in gastric juice was lower in patients with DU than in those with PU. There are a considerable number of patients who possess features of both duodenal and prepyloric ulcer disease. The clinical outcome of both continuous cimetidine treatment and vagotomy in these patients (DU/PU and PU/DU) was less satisfactory than in pure DU. All patients presenting with active DU should therefore be investigated for evidence of previous prepyloric ulceration.

Symptomatic recurrence of healed duodenal and prepyloric ulcers after treatment with ranitidine or high-dose antacid. A 1-year follow-up study

Eighty-seven patients with duodenal (n = 49) or prepyloric (n = 38) ulcers healed with ranitidine (n = 44) or a high-dose liquid antacid (n = 43) completed a 1-year double-blind comparative study of symptomatic relapse without treatment. Both duodenal ulcers and prepyloric ulcers tended to remain true to their type of recurrence. Age, sex, history of ulcer disease, duration of initial treatment, and smoking habits were all without influence on the relapse rates. The subgroup of patients with a duodenal ulcer who had healed on either treatment regimen had a symptomatic relapse significantly more frequently than those with prepyloric ulcer (64% +/- 13 versus 34% +/- 15; p less than 0.025), but the estimated probabilities of relapse were unaffected (p greater than 0.05) by the initial type of medication (ranitidine group, 56% +/- 15; antacid group, 51% +/- 15). Thus the present study could not confirm the hypothesis that patients treated with H2-receptor antagonists tend to relapse earlier than those treated with antacids during the following year without treatment.

Results of short- and long-term cimetidine treatment in patients with juxtapyloric ulcers, with special reference to gastric acid and pepsin secretion

One hundred and seven patients with active juxtapyloric ulcers and a history of chronic ulcer disease were treated with cimetidine. After ulcer healing 67 patients were selected for medical management, testing the value of cimetidine maintenance treatment. Time to healing was shorter for patients with duodenal ulcers when compared with those with active prepyloric ulcers. Recurrences were fewer for patients with pure duodenal ulcer disease (DUD) when compared with those with active or previous prepyloric ulcer disease (PUD). Patients whose ulcers were slow to heal and those with active or previous prepyloric ulcers (PUD) required a higher dose of cimetidine for effective control of their disease. All patients with slowly healing ulcers (more than 6 weeks) relapsed with 400 mg cimetidine at night. Among patients with relapse 46% with DUD and 31% with PUD were controlled by increasing cimetidine to 400 mg twice daily. Tests of acid secretion were of no value in predicting the rate of ulcer healing or relapse rate. Pepsin secretion studies, however, were of predictive value for patients with DUD but of indeterminate value for patients with PUD. Long-term cimetidine produced a significant decrease in pentagastrin-stimulated pepsin secretion (without treatment) in both patients with and without relapse. No significant changes in acid secretion were observed. As a result of these studies we recommend a cimetidine maintenance dosage of 400 mg twice a day for all patients whose ulcers are slow to heal on 1 g cimetidine a day and in patients with prepyloric ulcer disease regardless of rate of healing.