Powerful gastric acid inhibition: when is it justified?

Peptic ulcers fail to heal in up to 10% of patients after 8 weeks of therapy with H2-receptor antagonists largely owing to the multifactorial pathogenesis of the disease. Site-protective agents may heal the ulcers in many, but not all, of these non-responders. In ulcers which prove particularly refractory to therapy, only powerful gastric acid inhibition of the type best achieved with omeprazole is capable of healing most, and sometimes even 100% of patients in the short term. Powerful inhibition of gastric acid secretion proves clinically advantageous, in terms both of symptom relief and endoscopic lesions, in severe reflux oesophagitis, characterized, as it is, by erosive and ulcerative lesions. Strong inhibition of acid secretion is, of course, also indicated in Zollinger-Ellison syndrome, the treatment of which has already been revolutionized by the use of H2-antagonists, usually given in very high doses, and appears to have made yet another step forward with the advent of omeprazole thanks to the particularly marked potency and duration of action of this benzimidazole derivative. Powerful inhibition of acid secretion thus seems possible both with high-dose H2-antagonists and, most notably, with omeprazole. Though fully justified in certain classic conditions such as refractory ulcer, erosive-ulcerative oesophagitis and Zollinger-Ellison syndrome, massive antisecretory blockade would not appear to be suitable for indiscriminate use, especially long-term.