Goals of therapy: aggressive or moderate acid suppression?

Healing with moderate acid suppression is increasingly becoming the goal of therapy in patients with peptic ulcer. Comparative trials between cimetidine and other more potent H2-receptor antagonists indicate no difference in efficacy or pain relief despite the higher degree of acid suppression induced by the newer agents. Recent clinical trials with cimetidine have demonstrated that the inhibition of nocturnal acid secretion alone is the most important factor in the healing of peptic ulcer. The results of clinical trials conducted in the United States and Europe demonstrated that 800 mg of cimetidine at bedtime is the optimal dosage regimen, providing rapid pain relief and ulcer healing in approximately 80% of the patients. Furthermore this regimen has the advantages of easy compliance, convenience, and fewer potential drug interactions, as well as providing 24-hour moderate acid suppression with normal daytime gastric acid levels. Thus in ambulatory patients with duodenal ulcer, a single nightly dose of 800 mg of cimetidine is the optimal regimen for moderate acid suppression. This reinforces a basic concept of medicine that the lowest possible dosage of a drug can be used to treat a condition effectively and safely. While moderate acid suppression with nocturnal dosing will accomplish the goal of healing in the ambulatory patient, different objectives of acid-suppression therapy may be needed when treating hospitalized patients in the intensive care unit. For these patients, well-controlled clinical trials indicate the necessity for a more aggressive approach to gastric acid control, with the goal being to maintain the intragastric pH above 4.0.