Evidence-based clinical practice guidelines for peptic ulcer disease 2020

Abstract

The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an English version. The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs). Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers. Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence.

Keywords: Helicobacter pylori eradication; Idiopathic ulcer; Low-dose aspirin; Nonsteroidal anti-inflammatory drug; Peptic ulcer.

Fig. 1

Forest plots of proton pump inhibitors (PPIs) against control for upper gastrointestinal bleeding preventive effect in dual antiplatelet therapy (DAPT). In meta-analysis, PPIs significantly have reduced bleeding risk compared to controls (RR 0.26; 95%CI 0.13–0.53, P = 0.0002)

Fig. 2

Forest plots of eradication rates of first-line therapy between vonoprazan-containing triple therapy and proton pump inhibitor (PPI)-containing triple therapy in the randomized control trials. In meta-analysis, the eradication rates of vonoprazan-containing triple therapy are significantly higher than that of PPI-containing triple therapy (odds ratio 0.28; 95% CI 0.19–0.41, P < 0.00001)

Fig. 3

Forest plots of eradication rates of second-line therapy between proton pump inhibitor/amoxicillin/metronidazole (PAM) therapy and proton pump inhibitor/amoxicillin/clarithromycin (PAC) therapy in the randomized control trials in Japan. In meta-analysis, the eradication rates of PAM therapy are significantly higher than that of PAC therapy (odds ratio 0.14; 95% CI 0.08–0.24)

Fig. 4

Meta-analysis of comparison of ulcer curative effect between PPI and H₂RA under the NSAIDs continuation. In meta-analysis, the healing rate of peptic ulcers for 8 weeks is higher in the PPI groups than in the H₂RA groups

Fig. 5

Meta-analysis of preventive effect in the secondary prevention of NSAIDs ulcer. In meta-analysis, the recurrence rate of peptic ulcers in patients with a history of gastric or duodenal ulcers who required long-term NSAID therapy is lower in the PPI groups than in the placebo groups

Fig. 6

Forest plots of peptic ulcer risk between COX-2 selective inhibitor and NSAID therapy in the randomized control trials (a gastric ulcer, b duodenal ulcer). In meta-analysis, the incidence of gastric (risk ratio 0.21; 95% CI 0.18–0.25) (a) and duodenal ulcers (risk ratio 0.38; 95% CI 0.29–0.51) (b) are lower in patients using COX-2 selective inhibitors than in patients using NSAIDs

Fig. 7

Effects of proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H₂RAs) in preventing upper gastrointestinal (GI) ulcers related to low dose aspirin (LDA). An independently meta-analysis demonstrates that no significant difference (RR 0.26; 95% CI 0.04–1.81, P = 0.17) in the incidence of LDA-related upper GI ulcers between PPIs and H₂RAs

Fig. 8

Effects of proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H₂RAs) in preventing upper gastrointestinal (GI) ulcer bleeding related to low dose aspirin (LDA). An independently meta-analysis demonstrated that PPIs are superior to H₂Ras (RR 0.28; 95% CI 0.16–0.50, P < 0.0001) in prevention of LDA-related upper GI bleeding

Fig. 9

Algorithm for the treatment of peptic ulcer disease

Fig. 10

Algorithm for the prevention of NSAID-induced ulcers

Fig. 11

Algorithm for the prevention of LDA-related ulcers