The medical treatment of peptic ulcer disease:

The management of peptic ulcer disease

PURPOSE OF REVIEW

The period under review has seen little evolution in our understanding of the empiric management of dyspepsia. The role of Helicobacter pylori in this setting remains controversial, and a policy of risk stratification with the prudent use of test and treat and symptomatic therapy, with endoscopy for nonresponsive cases, seems to have some support from the literature in this period.

RECENT FINDINGS

The management of nonsteroidal antiinflammatory drug-associated and aspirin-associated complications has received a lot of attention in the period under review. The COX-2 selective agents have maintained their reputation as safer (but not "safe") options, although some of the original work with one of these agents has been rigorously interrogated and found wanting. Studies in the review period have focused our attention on the less than satisfactory protection of proton pump inhibitor cotherapy, the site-specific nature of ulcer recurrences (which may have therapeutic implications), lower gastroenterology complications associated with NSAID use, and the beneficial effect of proton pump inhibitor cotherapy for patients receiving low-dose aspirin. One should also expect a lot more information in the future with regard to the use of the nitric oxide donating class of nonsteroidal antiinflammatory drugs and aspirin.

SUMMARY

Findings are presented that suggest that the H.pylori stool antigen test is not as reliable as the urea breath test, while the most promising "new therapy" for H. pylori is not new, but rather an amalgam of some older drugs combined in a new "quadruple" therapy strategy, which shows some promise.

Peptic ulcer disease

The introduction of the "Maastricht 2-2000" document provides some guidance with regard to the management of Helicobacter pylori infection in both primary and specialist practice settings, albeit primarily in the European setting. The putative role of H. pylori in gastric carcinogenesis was supported by a further study. Studies on the natural history of peptic ulcer disease (PUD) highlight the particular vulnerability of the elderly patient to PUD and its complications, and focus attention on targeted intervention in this group, particularly the avoidance of nonsteroidal antiinflammatory drugs (NSAID). Little has evolved with regard to the introduction of new NSAID, but reports indicate the potential association of cyclooxygenase-2 (COX 2)-selective agent use with an increased risk of cardiovascular events. The role of H. pylori and NSAID as risk factors for peptic ulcer disease and its complications is again explored, and both meta-analysis and clinical studies provide some evidence of their synergistic effect. The introduction of esomeprazole, the S-isomer of omeprazole, has widened the clinician's therapeutic choice; the true value of this agent remains to be determined.