Management of Acid-Peptic Disease

Initial Strategy: Test and Treat for H. pylori

• The American Gastroenterological Association recommends that all patients with dyspepsia without alarm symptoms should receive non-invasive testing for Helicobacter pylori and, if infected, eradication therapy to eliminate the risk of peptic ulcer mortality 1.
• The European Society for Primary Care Gastroenterology suggests that only 5% of symptomatic improvement in functional dyspepsia is attributed to eradication 2.

Diagnostic Tests

• The American College of Gastroenterology recommends urea breath test or stool antigen test (not serology) for diagnosing H. pylori infection 1, 2.
• Confirmation of successful eradication is only recommended in patients with increased risk of gastric cancer 1.

Acid Suppression Therapy

• The American College of Cardiology recommends that proton pump inhibitors (PPIs) are the first-line treatment for acid-peptic disease, superior to H2 antagonists in efficacy 1.
• PPIs should be administered 30-60 minutes before a meal 3, 2.

H. pylori Eradication

• The Infectious Diseases Society of America recommends that potassium-competitive acid blockers (P-CABs) should be used instead of PPIs in eradication regimens for most patients with H. pylori infection 4.
• P-CABs demonstrate higher eradication rates (92% vs 80%) and are particularly effective in clarithromycin-resistant infections (66-70% vs 32%) 4.

Established Peptic Ulcer Disease

• The American Gastroenterological Association recommends that PPIs are the standard treatment for healing peptic ulcers 4.
• Vonoprazan 20 mg showed non-inferiority to lansoprazol 30 mg for healing gastric and duodenal ulcers 4.

Long-term Management

• The European Society for Primary Care Gastroenterology suggests that PPIs should be titrated to the lowest effective dose once symptoms are controlled 1, 3, 2.
• Consider on-demand therapy for maintenance 6, 2.

Functional Dyspepsia

• The American College of Gastroenterology recommends that PPIs are the first choice for ulcer-like dyspepsia (dominant epigastric pain) 6, 8, 9.
• For dysmotility-like dyspepsia (fullness, distension, satiety), consider prokinetic agents 1, 6.

Refractory Symptoms

• The American Gastroenterological Association recommends an escalation algorithm for refractory symptoms, including verifying compliance and optimizing PPI dosage, changing from prokinetic to PPI or vice versa, and considering high-dose PPI 6, 8, 2.
• Refer to endoscopy if symptoms persist after changing therapy 6, 8.