Maintenance therapy for peptic ulcer--who needs it?

Until recently, peptic ulcer disease implied lifelong susceptibility to symptomatic, asymptomatic or complicated ulcer recurrences. Only about 50% of the ulcers seen endoscopically ever become symptomatic. Asymptomatic ulcers appear clinically unimportant, except in the setting of aspirin (ASA) or NSAID use, where they may lead without warning to fatal complications. Until recently, ulcer disease could not be cured medically: no drug has been shown to prevent ulcer complications occurring in patients taking ASA/NSAIDs. Low-dose maintenance therapy with H2-antagonists reduces recurrences and complications, but is expensive and requires indefinite use. Other anti-ulcer drugs have not been studied enough to conclude with confidence that they are similarly effective. Over 80% of recurrences are infrequent and can be treated when they occur n 20% of ulcer patients have 3 recurrences/yr, ulcer complications, or such poor health that recurrence might prove fatal. Ulcers recurring during maintenance therapy rarely complicate and heal with increasing and maintaining dosage. Eradication of H. Pylori (HP) infection, while difficult, abolishes most recurrences without maintenance therapy. Maintenance therapy is therefore indicated principally when HP can not be eradicated. Surgery is rarely required for uncomplicated disease.