Managing peptic ulcer disease in adults

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flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-
disease
NICE Pathway last updated: 03 October 2017

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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 Managing peptic ulcer disease in adults NICE Pathways

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 Managing peptic ulcer disease in adults NICE Pathways

1 Adult with peptic ulcer disease

No additional information

2 Initial treatment

Offer H. pylori eradication therapy to people who have tested positive for H. pylori and who have
peptic ulcer disease.

For people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible.
Offer full-dose PPI (see table) or H2RA therapy for 8 weeks and, if H. pylori is present,
subsequently offer eradication therapy.

Proton pump inhibitor doses relating to evidence synthesis and recommendations in

NICE guideline CG17

Proton pump Full/standard Low dose (on-demand

Double dose
inhibitor dose dose)

1
40 mg2 once a
Esomeprazole 20 mg once a day Not available
day

30 mg3 twice a
Lansoprazole 30 mg once a day 15 mg once a day
day

40 mg once a
Omeprazole 20 mg once a day 10 mg once a day
day

40 mg twice a
Pantoprazole 40 mg once a day 20 mg once a day
day

20 mg twice a
Rabeprazole 20 mg once a day 10 mg once a day
day

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1
Lower than the licensed starting dose for esomeprazole in gastro-oesophageal reflux disease, which is 40 mg, but
considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of dose-related effects, NICE
classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.
2
40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to
omeprazole 20 mg.
3
Off-label dose for gastro-oesophageal reflux disease.

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 Managing peptic ulcer disease in adults NICE Pathways

3 H. pylori testing and eradication

See Dyspepsia and gastro-oesophageal reflux disease / Helicobacter pylori testing and
eradication in adults

4 Proton pump inhibitor or H2 receptor antagonist therapy

Offer full-dose PPI (see table) or H2RA therapy for 4 to 8 weeks to people who have tested
negative for H. pylori who are not taking NSAIDs.

Proton pump inhibitor doses relating to evidence synthesis and recommendations in

NICE guideline CG17

Proton pump Full/standard Low dose (on-demand

Double dose
inhibitor dose dose)

40 mg2 once a
Esomeprazole 20 mg1 once a day Not available
day

30 mg3 twice a
Lansoprazole 30 mg once a day 15 mg once a day
day

40 mg once a
Omeprazole 20 mg once a day 10 mg once a day
day

40 mg twice a
Pantoprazole 40 mg once a day 20 mg once a day
day

20 mg twice a
Rabeprazole 20 mg once a day 10 mg once a day
day

1
Lower than the licensed starting dose for esomeprazole in gastro-oesophageal reflux disease, which is 40 mg, but
considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of dose-related effects, NICE
classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg.

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2
40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to
omeprazole 20 mg.
3
Off-label dose for gastro-oesophageal reflux disease.

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 Managing peptic ulcer disease in adults NICE Pathways

5 Endoscopy and retesting for H. pylori

Offer people with gastric ulcer and H. pylori repeat endoscopy 6 to 8 weeks after beginning
treatment, depending on the size of the lesion.

Offer people with peptic ulcer (gastric or duodenal) and H. pylori retesting for H. pylori 6 to 8
weeks after beginning treatment, depending on the size of the lesion.

Perform re-testing for H. pylori using a carbon-13 urea breath test. (There is currently
insufficient evidence to recommend the stool antigen test as a test of eradication.1)

6 Continued non-steroidal anti-inflammatory drug use

For people continuing to take NSAIDs after a peptic ulcer has healed, discuss the potential
harm from NSAID treatment. Review the need for NSAID use regularly (at least every 6 months)
and offer a trial of use on a limited, 'as-needed' basis. Consider reducing the dose, substituting
an NSAID with paracetamol, or using an alternative analgesic or low-dose ibuprofen (1.2 g
daily).

In people at high risk (previous ulceration) and for whom NSAID continuation is necessary,
consider a COX-2 selective NSAID instead of a standard NSAID. In either case, prescribe with a
PPI.

7 Unhealed ulcer

In people with an unhealed ulcer, exclude non-adherence, malignancy, failure to detect H. pylori,
inadvertent NSAID use, other ulcer-inducing medication and rare causes such as
Zollinger–Ellison syndrome or Crohn's disease.

See what NICE says on Crohn's disease.

8 If symptoms continue or recur

If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to
control symptoms. Discuss using the treatment on an 'as-needed' basis with people to manage
their own symptoms.

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 Managing peptic ulcer disease in adults NICE Pathways

Offer H2RA therapy if there is an inadequate response to a PPI.

9 Ongoing care

See dyspepsia and gastro-oesophageal reflux disease/dyspepsia and gastro-oesophageal

reflux disease in adults /Ongoing care

1
This refers to evidence reviewed in 2004.

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Managing peptic ulcer disease in adults NICE Pathways

Glossary

H. pylori

Helicobacter pylori

H2RA

H2 receptor antagonist

NSAID

non-steroidal anti-inflammatory drug

PPI

proton pump inhibitor

Sources

Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management

(2014) NICE guideline CG184

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They

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Managing peptic ulcer disease in adults NICE Pathways

should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the

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Managing peptic ulcer disease in adults NICE Pathways

interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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