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Upon completion of the chapter, the reader will be able to:

  1. Recognize differences between ulcers induced by Helicobacter pylori (H. pylori), nonsteroidal anti-inflammatory drugs (NSAIDs), and stress-related mucosal damage (SRMD) in terms of risk factors, pathogenesis, signs and symptoms, clinical course, and prognosis.

  2. Identify desired therapeutic outcomes for patients with H. pylori–associated and NSAID-induced ulcers.

  3. Select an appropriate H. pylori eradication regimen that considers patient-specific factors and approaches to improve regimen adherence.

  4. Determine the appropriate management for a patient taking a nonselective NSAID who is at high risk for ulcer-related gastrointestinal (GI) complications (eg, GI bleed) or who develops an ulcer.

  5. Utilize an algorithm for the evaluation and treatment of a patient with signs and symptoms suggestive of an H. pylori–associated or NSAID-induced ulcer.

  6. Given patient-specific information and a prescribed treatment regimen, develop a monitoring plan for drug therapy to eradicate H. pylori or treat an active NSAID-induced ulcer or GI complication.


Peptic ulcer disease (PUD) refers to a defect in the gastric or duodenal mucosal wall that extends through the muscularis mucosa into the deeper layers of the submucosa.1 PUD is a significant cause of morbidity and associated with substantial health care costs.2,3 Although there are many etiologies of PUD, the three most common are (a) Helicobactor pylori (H. pylori) infection, (b) use of nonsteroidal anti-inflammatory drugs (NSAIDs), and (c) stress-related mucosal damage (SRMD).

Complications of PUD include gastrointestinal (GI) bleeding, perforation, and obstruction. Complications of untreated or undiagnosed H. pylori infection include gastric cancer and PUD. This chapter focuses mainly on pharmacotherapy of PUD related to H. pylori infection or NSAID use. Prophylaxis of SRMD in hospitalized patients is discussed briefly.


PUD affects approximately 10% of women and 12% of men in the United States, resulting in 4 million cases annually.4 The mean direct medical cost (including pharmacy, inpatient, and outpatient costs) was $23,819 per patient per year in one study evaluating workplace absences, short-term medical disability, worker’s compensation, and medical and pharmacy claims for six large US employers.5

The prevalence of H. pylori infection in the United States and Canada is about 30%, whereas the global prevalence is greater than 50%. Factors that influence the incidence and prevalence of H. pylori infection include age, ethnicity, sex, geography, and socioeconomic status.

Helicobacter Pylori

H. pylori is usually contracted in the first few years of life and tends to persist indefinitely unless treated. The infection normally resides in the stomach and is transmitted through ingestion of fecal-contaminated water or food. The organism causes gastritis in all infected individuals, but fewer than 10% will develop symptomatic PUD.

Nonsteroidal Anti-Inflammatory Drugs

Nearly half of people with chronic NSAID ...

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