Formulary management of antiulcer drugs: clinical considerations

Peptic ulcer disease (PUD) is thought to result from an imbalance between aggressive (excessive) {especially gastric acid and pepsin} and protective (diminished) factors (gastric mucus and bicarbonate, prostaglandins and others) in the stomach. Recent attention has focused on the role of Helicobacter pylori as a cause of chronic active gastritis and a pathogenic factor in PUD. Antiulcer medications with proven efficacy in the treatment of acute PUD include histamine 2 (H 2)-receptor antagonists, H +/K +-ATPase (proton pump) inhibitors, antacids, sucralfate and prostaglandin analogues. The advent of proton pump inhibitors in particular has resulted in effective therapy for ulcers that previously would have been considered refractory. H 2-receptor antagonists and sucralfate are also useful for maintenance therapy of PUD. Recent interest has focused on strategies aimed at eradicating H. pylori and the ensuing change in the natural history of PUD, specifically a marked decrease in ulcer recurrence. In contrast, with standard treatment regimens there is a high rate of ulcer relapse (50 to 90%) after acute ulcer healing. Eradication of H. pylori has until now required a triple drug regimen of bismuth and 2 antibiotics, and is too cumbersome for routine use. It is likely, however, that treatment aimed at eradicating H. pylori will be routine in the near future and will represent a cost-effective alternative to standard long term maintenance therapy.