Relapse rate as a major determinant of drug selection in peptic ulcer therapy

Dopamine agonists prevent duodenal ulcer relapse. A comparative study with famotidine and cimetidine

The present study investigated both the healing rate (after four weeks) and the relapse rate (during six months) following treatment with the dopamine-like drugs bromocriptine (2.5 mg twice daily), amantadine (100 mg nocte), or with the H2 blockers cimetidine (800 mg nocte), and famotidine (40 mg nocte) in 124 patients with endoscopically proven duodenal ulcer (DU). The ulcer was completely healed in 27 (amantadine), 26 (bromocriptine), 23 (cimetidine), and in 24 (famotidine) patients. Relapse was noted in 34.7% (cimetidine) and 25% (famotidine) versus 11.7% (amantadine) and 7.7% (bromocriptine) DU patients. No significant difference was found in initial healing rates. However, the relapse rate in the cimetidine-treated group was significantly higher than in all the other test groups. Additional comparisons between all the treatment categories showed a significantly lower relapse rate with the dopamine-like agents. These important new results indicate that dopamine-like compounds are equally effective as H2 blockers in inducing DU healing and may offer a promising advantage over H2 blockers concerning their efficacy in preventing ulcer relapse in DU patients.

Maintenance therapy in peptic ulcer disease

The maxim "once an ulcer, always an ulcer" is still an appropriate description for the chronic nature of peptic ulcer disease. The goals for treating patients with ulcer disease are to relieve symptoms, heal the acute ulcer, reduce the risk of ulcer recurrence and complications, and decrease the economic impact of this chronic disease while maintaining the patient's quality of life. Patients with documented peptic ulcer disease should be carefully evaluated and a treatment plan devised that takes into account the possible need for maintenance therapy. Risk factors that seem to reflect a high likelihood of ulcer recurrence should be identified early in all ulcer patients and attempts made to minimize or correct them in the future. Assuming that a diagnosis of peptic ulcer disease has been firmly established and an adequate period of drug treatment makes complete ulcer healing likely, a reasonable way to proceed is outlined in Figure 4. If the patient is young and generally healthy, has an uncomplicated ulcer and few risk factors favoring ulcer relapse, either no treatment or symptomatic selfcare would be reasonable. If one chooses the latter course, the patient can be given a prescription for 3 to 6 months of medication and told to take full therapy for any recurrent symptoms, continuing the treatment until symptoms are relieved. The failure of such treatment to relieve symptoms after 2 to 3 weeks, the onset of alarming symptoms such as intense pain, vomiting, or melena, or possibly the exhaustion of the 6-month supply of medication with continued mild symptoms should lead to reevaluation. Alternatively, such a patient could be managed with no therapy and seen again if ulcer symptoms recur and reevaluated for further diagnosis and treatment. Obviously, patients who are candidates for these approaches to postulcer healing management are those with a low risk for ulcer recurrence and who are likely to be compliant with follow-up advice. Accordingly, careful patient selection seems most important in prescribing symptomatic self-care or intermittent full-dose maintenance treatment. On the other hand, if the patient has had a complicated course of ulcer disease, such as bleeding, or has a significant number of risk factors that would make early ulcer relapse highly likely, it would be prudent to institute continuous maintenance therapy while working to reduce or eliminate the adverse risk factors. Any relapse of symptomatic ulcer disease during noncontinuous maintenance therapy should indicate the need for return to a continuous dosing program.(ABSTRACT TRUNCATED AT 400 WORDS)

Campylobacter pylori and peptic ulcer disease

Campylobacter pylori is now known to be the most common and important cause of gastritis, and C. pylori infections have been associated with duodenal ulcer, gastric ulcer, nonulcer dyspepsia, and gastric cancer. Although it has been only possible to culture C. pylori for about 5 yr, there are already sufficient data available to allow us to develop the basic framework that relates C. pylori gastritis to the causation of peptic ulcer disease. We review the data and propose mechanisms that implicate C. pylori as an important factor in the pathogenesis of peptic ulcer disease and consider the therapeutic implications. What we now know about C. pylori begins to unravel some of the mysteries surrounding peptic ulcer disease.

Campylobacter pylori as a pathogenetic factor in duodenal ulcer: the case for

This debate addresses whether Campylobacter pylori contributes to the development and maintenance of chronic peptic ulcer disease. C. pylori may be both an aggressive factor and may also impair mucosal defence. C. pylori causes the inevitably ulcer-associated gastritis and duodenitis and eradication of the C. pylori infection is associated with resolution of the inflammation and virtual elimination of the problem of duodenal ulcer relapse. A model is suggested that requires two separate factors to combine to cause chronic duodenal ulcer disease with other environmental factors (e.g. smoking) modifying the interaction between C. pylori and genetic susceptibility. Both genetic susceptibility and C. pylori infection are required to produce duodenal ulcer disease; neither alone is sufficient. C. pylori is the most important factor in the pathogenesis of duodenal ulcer disease because it is the only pathogenetic factor that can be easily reversed by medical therapy.

Campylobacter pylori and gastroduodenal ulcer disease. A prospective study in a Swedish population

In a consecutive prospective series of 208 Swedish primary peptic ulcer patients, 146 gastric, 55 duodenal and 7 in both sites, gastroduodenitis was found in 97.6% of the cases. The mucosal inflammation was associated with CP in 87% and 91% of the gastric and duodenal ulcer cases respectively. No significant correlation was found between CP colonisation and the type or severity of mucosal inflammation. Gastric metaplasia was present in only 8% of 48 bulbar ulcer cases. Ulcer healing and eradication of CP was achieved in 52% of patients treated with bismuth subnitrate in combination with erythromycin or according to the triple approach.

Absorption and elimination of bismuth from oral doses of tripotassium dicitrato bismuthate

The pharmacokinetics of bismuth subcitrate were studied in plasma and urine under conditions of single and multiple dosing (28-56 days) using atomic absorption technique. Single dose plasma pharmacokinetics showed peak concentrations of 5.5-57.5 micrograms.l-1 (mean = 24.7 micrograms.l-1), reached between 30 and 60 min post dosing with an apparent biphasic elimination pattern. Multiple dose studies showed a continuing rise in plasma concentration and urine excretion rate reaching apparent steady-state levels over 7-29 days (mean = 18 days). Washout studies in 6 individuals reciprocated accumulation. Maximum equilibrated plasma levels of 7.6-58.3 micrograms.l-1 (mean = 38.3 micrograms.l-1) were well below those associated with encephalopathy. The half-life of bismuth elimination was 20.7 days. Present patterns of intermittent dosing with bismuth are unlikely to be associated with bismuth accumulation despite slow accumulation and elimination.