Treatment of Peptic Ulcer: 2020 JSGE Evidence-Based Clinical Practice Guidelines (Part 1) | Guidelines Consensus

Guide to the 2020 edition of the Japanese Society of Gastroenterology (JSGE) Clinical Practice Guidelines for Peptic Ulcer is the third edition of the guidelines.
The main content involves hemorrhagic gastric and duodenal ulcers, Helicobacter pylori eradication treatment, non-eradicative treatment, and drugs Ulcers, non-Helicobacter pylori non-non-steroidal anti-inflammatory drug (NSAID) ulcers, gastric ulcers and surgical treatment.

This guide uses the Recommendation, Evaluation, Development, and Evaluation Grading (GRADE) to classify the quality of evidence into A (high), B (medium), C (low), and D (very low).

The recommendation strength is divided into "strong recommendation" or "weak recommendation".

1.
Non-endoscopic hemostatic treatment of hemorrhagic gastric and duodenal ulcer 1.
Should patients with hemorrhagic peptic ulcer be given anticoagulant and/or antiplatelet drug treatment? (1) Patients with high risk of thromboembolism are recommended to continue using aspirin.

Strength of recommendation: strong; 100% agree; level of evidence: B.

(2) For patients with high risk of thromboembolism, it is recommended to change the antiplatelet drug to aspirin.

Strength of recommendation: weak; 100% agree; level of evidence: D.

(3) It is recommended to exclude patients with high risk of thromboembolism, and to suspend the use of antiplatelet drugs for the rest of the patients.

Strength of recommendation: weak; 100% agree; level of evidence: D.

(4) Patients with endoscopic hemostatic therapy are recommended to stop warfarin when necessary.

If warfarin is stopped, it is recommended to use heparin or resume warfarin treatment as soon as possible after hemostasis.

Strength of recommendation: strong; 100% agree; level of evidence: C.

(5) It is recommended to resume direct oral anticoagulant (DOAC) treatment as soon as possible (1-2 days) after confirming endoscopic hemostasis.

Strength of recommendation: weak; 100% agree; level of evidence: D.

(6) For patients receiving both antiplatelet drugs and warfarin treatment, it is recommended to change the antiplatelet drugs to aspirin or cilostazol.

Continue warfarin treatment or change warfarin to heparin under the appropriate prothrombin time-international normalized ratio (PT-INR).

Strength of recommendation: weak; 100% agree; level of evidence: D.

(7) For patients receiving dual antiplatelet drug therapy (DAPT), it is recommended to continue to use aspirin alone.

Strength of recommendation: strong; 100% agree; level of evidence: D.

2.
Is Interventional Radiology (IVR) effective for patients undergoing endoscopic treatment of refractory hemorrhagic peptic ulcer? (1) For patients undergoing endoscopic treatment of refractory hemorrhagic peptic ulcer, considering the safety and effectiveness of IVR, IVR treatment is recommended.

Strength of recommendation: weak; 100% agree; Evidence level: C.

3.
After endoscopic treatment of hemorrhagic peptic ulcer, is it necessary to use antacids? (1) It is recommended to give proton pump inhibitor (PPI) after endoscopic treatment of hemorrhagic peptic ulcer to improve the treatment outcome.

Strength of recommendation: strong; 100% agree; level of evidence: A.

Prevention of hemorrhagic peptic ulcer 1.
What drugs are recommended for antithrombotic drug users to prevent hemorrhagic ulcers? (1) For patients receiving DAPT, it is recommended to use PPI in combination to prevent upper gastrointestinal bleeding (UGIB).

Strength of recommendation: strong; 100% agree; level of evidence: A.

(2) If you are taking warfarin, it is recommended that patients taking antiplatelet drugs or NSAIDs use PPI to prevent UGIB.

Strength of recommendation: weak; 100% agree; Evidence level: C.

2.
Helicobacter pylori eradication therapy first-line eradication therapy 1.
Which plan should be chosen for first-line eradication therapy of Helicobacter pylori? (1) Since the eradication rate of voronolazan (VPZ) + amoxicillin + clarithromycin triple therapy is higher than that of PPI, VPZ is recommended as the first-line treatment.

Strength of recommendation: strong; 100% agree; level of evidence: A.

(2) Antibiotics recommended for first-line treatment include amoxicillin, clarithromycin, or metronidazole.

In Japan, due to the high incidence of clarithromycin-resistant strains, the combination of amoxicillin and metronidazole is recommended.

Strength of recommendation: strong; 100% agree; level of evidence: A.

(3) When using PPI, since the eradication rate of five-line therapy is higher than that of triple therapy, it is recommended to use sequential therapy and quadruple companion therapy.

Strength of recommendation: weak; 100% agree; level of evidence: A.

Second-line eradication treatment 1.
For the second-line eradication treatment of Helicobacter pylori, which option should be selected? (1) It is recommended to use PPI/VPZ, amoxicillin and metronidazole triple therapy.

Strength of recommendation: strong; 100% agree; level of evidence: A.

Third-line eradication therapy 1.
Which option should be chosen for the third-line eradication therapy of Helicobacter pylori? (1) It is recommended to use PPI, sitafloxacin and metronidazole triple therapy, or PPI, sitafloxacin and amoxicillin triple therapy.

Strength of recommendation: weak; 100% agree; level of evidence: B.

Ulcer recurrence after Helicobacter pylori eradication 1.
Does peptic ulcer recurrence after successful eradication of Helicobacter pylori need maintenance treatment? (1) When the cause of peptic ulcer recurrence is not clear, it is recommended to use PPI or histamine 2 receptor antagonist (H2RA) for long-term maintenance treatment.

Strength of recommendation: weak; 100% agree; level of evidence: D.

3.
Non-eradicated treatment (initial treatment) gastric ulcer 1.
What is the first-line drug for the initial non-eradicated treatment of gastric ulcer? (1) It is recommended to use PPI or potassium ion competitive acid blocker (P-CAB).

Strength of recommendation: strong; 100% agree; level of evidence: A.

(2) If PPI and P-CAB cannot be prescribed, H2RA is recommended.

Strength of recommendation: strong; 100% agree; level of evidence: B.

(3) If PPI and P-CAB cannot be prescribed, it is recommended to use pirenzepine, sucralfate and misoprostol.

Strength of recommendation: weak; 100% agree; level of evidence: B.

(4) If none of the above drugs can be prescribed, it is recommended to use gastric mucosal protective agents (excluding sucralfate and misoprostol).

Strength of recommendation: weak; 100% agree; level of evidence: B.

Duodenal ulcer 1.
What is the first-line drug for initial non-eradicated treatment of duodenal ulcer? (1) It is recommended to use PPI or P-CAB.

Strength of recommendation: strong; 100% agree; level of evidence: A.

(2) If PPI and P-CAB cannot be prescribed, H2RA is recommended.

Strength of recommendation: strong; 100% agree; level of evidence: B.

(3) If PPI and P-CAB cannot be prescribed, it is recommended to use pirenzepine, sucralfate and misoprostol.

Strength of recommendation: weak; 100% agree; level of evidence: B.

To be continued.
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Follow-up will push the relevant content of the 2020 JSGE evidence-based clinical practice guidelines (below), including drug-induced ulcers, non-helicobacter pylori non-NSAID ulcers, residual gastric ulcers and surgical treatment.

Literature index: Kamada T, Satoh K, Itoh T, et al.
Evidence-based clinical practice guidelines for peptic ulcer disease 2020[J].
J Gastroenterol.
2021 Feb 23.
Contribution email: tougao@medlive.
cn