Aspirin and anti-inflammatory medications cause ulcers and ulcer complications such as bleeding or a hole through the stomach wall (perforation) in approximately 25% of all individuals who use them. Approximately 100,000 people are admitted to the hospital each year because of ulcer complications from anti-inflammatory drugs, and 10,000 to 20,000 die annually due to these complications.

Certain individuals are at especially high risk from anti-inflammatory drugs including those who are older, who use steroids, take high doses of anti-inflammatory drugs, and those with previous ulcers or ulcer complications.

Anti-inflammatory-caused complications, such as ulcer bleeding, often occur silently, without symptoms (as many as 60%). Individuals with a history of ulcers who must take anti-inflammatory drugs to treat severe arthritis, for example, should use ulcer-preventing medications such as H2-blockers (Tagamet, Zantac, Pepcid, Axid) or misoprostol, a medication that is highly effective in preventing anti-inflammatory-related ulcers.

Some of the newer anti-inflammatory drugs, celecoxib (Celebrex), nabumetone (Relafen) and etodoluc (Lodine), are thought to pose less risk for ulcers but further studies are needed to confirm this.

H pylori is a recently discovered bacteria that causes ulcers. Its discovery has revolutionized ulcer treatment. H pylori-caused ulcers are treated with antibiotics rather than traditional anti-acid drugs. Approximately 90% of all ulcers are caused by either H pylori or anti-inflammatory pain medications (aspirin, Motrin, Advil, Aleve, ibuprofen, etc). H pylori is the major cause of ulcer recurrence. Curing H pylori is highly effective in healing ulcers and in preventing ulcer recurrence.

There is some controversy about which patients should be treated for H pylori. Most experts recommend that recurring ulcers are best treated with antibiotics if H pylori is present.

H pylori-caused ulcers are an infectious disease and can be passed from person to person, particularly among family members and others who are in close contact. The bacteria are present in stools and in vomit. Good hand-washing habits after using the bathroom may help prevent the spread of the infection.

Omeprazole is one of the most powerful ulcer treatments and is commonly used for hard-to-heal ulcers. Omeprazole can heal more than 90% of ulcers with 4 weeks of treatment. It causes infrequent side effects and can be taken once a day.

There has been concern that long term use of omeprazole and lansoprazole might increase the risk of stomach cancer in certain patients who have other pre-existing conditions (chronic fundic atrophic gastritis, pernicious anemia, or Zollinger-Ellison syndrome).

There is also concern about an increased cancer risk in patients who have H pylori infections who are treated with long term omeprazole or lansoprazole. Despite a lack of hard evidence, many physicians recommend curing H pylori infections before considering long term treatment with omeprazole or lansoprazole.

Ranitidine can heal up to 80% to 95% of ulcers with 6 to 8 weeks of treatment. Ranitidine causes infrequent side effects (less than 3%). It is easy to use since it can be taken once a day and is available over the counter. Ranitidine doses not interact with as many drugs as cimetidine, another H2-blocker.

Nizatidine can heal up to 80% to 95% of ulcers with 6 to 8 weeks of treatment. Nizatidine causes infrequent side effects (less than 3%). It is easy to use since it can be taken once a day and is available over the counter. Nizatidine doses not interact with as many drugs as cimetidine, another H2-blocker.

Cimetidine can heal up to 80% to 95% of ulcers with 6 to 8 weeks of treatment. Cimetidine causes infrequent side effects (less than 3%). It is easy to use since it can be taken once a day and is available over the counter. Cimetidine commonly causes problems when taken with certain medications.

Lansoprazole is one of the most powerful ulcer treatments and is commonly used for hard-to-heal ulcers. Lansoprazole can heal more than 90% of ulcers with 4 weeks of treatment. It causes infrequent side effects and can be taken once a day.

There has been concern that long term use of omeprazole and lansoprazole might increase the risk of stomach cancer in certain patients who have other pre-existing conditions (chronic fundic atrophic gastritis, pernicious anemia, or Zollinger-Ellison syndrome).

There is also concern about an increased cancer risk in patients who have H pylori infections who are treated with long term omeprazole or lansoprazole. Despite a lack of hard evidence, many physicians recommend curing H pylori infections before considering long term treatment with omeprazole or lansoprazole.

Famotidine can heal up to 80% to 95% of ulcers with 6 to 8 weeks of treatment. Famotidine causes infrequent side effects (less than 3%). It is easy to use since it can be taken once a day and is available over the counter. Famotidine doses not interact with as many drugs as cimetidine, another H2-blocker.

Rabeprazole is a newer acid inhibitor and, therefore, there is less information about its side effects compared to other drugs in its class. Rabeprazole is highly effective and can heal more than 90% of ulcers with 4 weeks of treatment.

There has been concern that long term use of acid inhibitors like rabeprazole might increase the risk of stomach cancer in certain patients who have other pre-existing conditions (chronic fundic atrophic gastritis, pernicious anemia, or Zollinger-Ellison syndrome).

There is also concern about an increased cancer risk in patients who have H pylori infections who are treated with long term acid inhibitor. Despite a lack of hard evidence, many physicians recommend curing H pylori infections before considering long term treatment with omeprazole or lansoprazole.

Sucralfate can heal 70% to 80% of ulcers at 4 weeks and 85% to 99% of ulcers at 8 weeks of treatment. Sucralfate considered very safe for short term use and causes almost no side effects except for constipation (3% of patients). There are questions about the safety of long term use. Sucralfate is inconvenient to use and must be taken 2-4 time a day. It can interfere with the absorption of several medications.

Antacids are as effective as H2-blockers, such as cimetidine, in healing ulcers. However, they must be taken 4 times a day and commonly cause side effects and, therefore, are not recommended for ulcers. Antacids are commonly used for indigestion that is not due to ulcers. Sodium bicarbonate is an antacid that can cause potentially serious salt and fluid overload. Overuse of calcium carbonate (Tums, Rolaids) can cause high blood levels of calcium and can affect the kidneys.

Pantoprazole is a newer acid inhibitor that is primarily used for severe indigestion and acid reflux. It is highly effective in healing ulcers but is not recommended because it can cause several extremely rare but very serious side effects including severe allergic reactions and dangerous skin reactions. Also, it has not been adequately tested for long term use.

Bismuth medications are not recommended for ulcer treatment because there are other more effective, safer drugs. Also, Bismuth can cause serious brain and nervous system problems if used in high doses or for prolonged periods of time.

Bismuth (BSS, Pepto-bismol) is approved for short term use for treatment of H pylori, a bacteria that causes ulcers. Pepto-bismol is available over the counter and is commonly used for diarrhea and minor stomach ailments.

Prostaglandins cause a high rate of side effects and have not been approved by the Federal Drug Administration (FDA) for ulcer treatment. (Exception - misoprostol.)

Tricyclic antidepressants are ineffective compared to other treatment options and commonly cause side effects.

Anticholinergics are ineffective compared to other treatment options. Anticholinergics, such as atropine, can cause dry mouth, blurred vision, and trouble urinating. Some newer anticholinergics may have fewer side effects but are still only half as effective as H2-blockers. They are no longer routinely used for ulcer treatment, as newer treatments are more effective.

Frequent meals or milk may increase stomach acid and may worsen ulcers.

Some foods, including spicy foods, can aggravate ulcer symptoms, but there is no evidence that they cause ulcers. Avoiding foods that aggravate ulcer symptoms is a good idea but this approach will not cure an ulcer.

Certain beverages such as coffee, tea, other caffeinated and decaffeinated beverages, sodas and cola-like drinks, beer and milk are potent stimulators of stomach acid production. It is not yet clear, however, whether these beverages can increase ulcer risk.

Carbenoxolone was used years ago for ulcer treatment. It can cause significant fluid retention and low blood potassium and is not considered safe.

Warning for all women of child-bearing age - there is a high risk of uterine bleeding from misoprostol during the first trimester of pregnancy. Misoprostol is highly effective in preventing ulcers caused by anti-inflammatory pain medications (Motrin, Advil, ibuprofen Aleve, etc). It is the only drug approved by the Federal Drug Administration (FDA) for this purpose. Misoprostol is more effective than H2-blockers or sucralfate in preventing ulcers caused by anti-inflammatory medications. It is inconvenient and must be taken four times a day. Misoprostol causes diarrhea in almost one-third of patients.

Prostaglandin medications can cause uterine bleeding in as many as one third of women during the first trimester of pregnancy. Prostaglandin medications can cause vaginal bleeding in postmenopausal women.

Colloidal bismuth subcitrate (CBS, De-Nol) is not available in the United States. It is widely used in Europe to treat H pylori, a bacteria that causes ulcers.

CBS should be used for short term treatment only. It has caused several cases of serious brain and nervous system complications when taken in high doses or for extended periods of time.