Omeprazole for stomach ulcers: doses, duration and follow-up

A peptic ulcer is a break in the lining of the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer).

Two causes account for the great majority of cases: infection with Helicobacter pylori, a bacterium that lives in the stomach lining, and regular use of NSAIDs such as ibuprofen, naproxen, diclofenac or aspirin.

Omeprazole is a proton pump inhibitor (PPI).

It blocks the enzyme system in the stomach's acid-producing cells - the proton pumps - and, taken once daily, reduces acid secretion by around 80%, keeping the stomach contents less acidic for most of the day.

Less acid means the ulcer crater is no longer being chemically irritated, which allows the mucosa to repair itself. Acid suppression does not kill H.

pylori or reverse NSAID damage on its own; it creates the conditions in which healing can take place.

• healing the ulcer with omeprazole for a defined period, and
• removing the cause - eradicating H. pylori with antibiotics, or stopping or reviewing NSAID use

Healing rates with omeprazole are high. In clinical studies, around 90% of duodenal ulcers heal within four weeks, and a similar proportion of gastric ulcers within eight weeks.

Symptoms often improve within days, but the ulcer itself takes weeks to close - which is why finishing the full course matters even when you feel better.

The dose and length of omeprazole treatment depend on where the ulcer is and what caused it. The regimens below follow the BNF; your own prescription may differ and always takes precedence.

Duodenal ulcer:

• 20 mg once daily for 4 weeks
• continued to 8 weeks if healing is incomplete
• 40 mg once daily can be used in refractory cases

Gastric (stomach) ulcer:

• 20 mg once daily for 8 weeks
• 40 mg once daily in refractory cases

NSAID-associated ulcer:

• 20 mg once daily for 4 to 8 weeks
• the NSAID should be stopped where possible; if it must continue, omeprazole is usually continued alongside it

How to take it: swallow the capsule whole with water, ideally 30 to 60 minutes before breakfast.

PPIs work best when taken before a meal, because they inactivate proton pumps that are actively secreting acid.

Do not crush or chew the capsules; dispersible formulations exist if swallowing is difficult.

A few practical points. Do not stop early because the pain has settled - symptom relief comes well before the ulcer has actually healed.

If you miss a dose, take the next one as scheduled rather than doubling up.

Higher doses and longer courses should only be used under medical supervision, since prolonged acid suppression carries its own considerations, covered in our article on long-term omeprazole use.

If testing shows H. pylori infection - usually by a stool antigen test or urea breath test - eradication therapy is essential.

Without it, ulcers recur in the majority of patients once the PPI is stopped; after successful eradication, recurrence falls to a few per cent.

Standard UK first-line treatment is triple therapy for 7 days:

• omeprazole 20-40 mg twice daily, plus
• amoxicillin 1 g twice daily, plus
• clarithromycin 500 mg twice daily or metronidazole 400 mg twice daily

For people allergic to penicillin, clarithromycin and metronidazole are combined instead of amoxicillin.

The choice between antibiotics also takes account of any courses you have had recently, because previous exposure increases the chance of bacterial resistance.

Tips for getting through the week:

• take both daily doses roughly 12 hours apart - missed doses are the main reason eradication fails
• avoid alcohol completely if the course includes metronidazole; the combination causes flushing, headache and vomiting
• mild nausea, a metallic taste and looser stools are common and settle when the course ends

After eradication therapy, omeprazole alone is usually continued to complete ulcer healing - typically to a total of 4 weeks for duodenal ulcers or 8 weeks for gastric ulcers.

In ulcer patients, re-testing is then recommended to confirm the infection has cleared: no sooner than 4 weeks after the antibiotics finish, and ideally 2 weeks after stopping the PPI, to avoid a falsely negative result.

NSAIDs - ibuprofen, naproxen, diclofenac and aspirin among them - damage the stomach lining in two ways: directly, and by blocking the prostaglandins that maintain the mucosa's protective barrier.

The risk of an NSAID ulcer rises with age, dose and duration of use.

Gastroprotection with omeprazole 20 mg once daily is recommended for people who need ongoing NSAID treatment and are at higher risk, including those who:

• are aged 65 or over
• have a history of peptic ulcer or gastrointestinal bleeding
• take other medicines that increase bleeding risk - anticoagulants such as warfarin or apixaban, antiplatelets such as clopidogrel or low-dose aspirin, corticosteroids, or SSRIs
• have a serious medical condition such as heart failure or diabetes
• need high-dose or long-term NSAID treatment

In practice this means taking omeprazole every day for as long as you take the NSAID - not just when your stomach feels unsettled. The protection stops when the PPI stops.

It is also worth asking whether the NSAID itself is still needed. Paracetamol or topical NSAID gels are reasonable alternatives for many musculoskeletal problems and avoid the issue entirely.

One caution: PPIs protect the stomach and duodenum, but they do not prevent NSAID damage further along the small bowel. The safest NSAID dose is the lowest one for the shortest time.

If you develop new indigestion, black stools or unexplained tiredness while on an NSAID, stop it and contact your GP promptly.

Follow-up differs between gastric and duodenal ulcers, and it is worth understanding why.

Gastric ulcers: repeat endoscopy is standard. A small proportion of stomach ulcers are not benign - an ulcerated gastric cancer can look identical to a simple ulcer at the first examination.

For this reason, UK practice is to repeat the gastroscopy 6 to 8 weeks after starting treatment, to confirm the ulcer has fully healed and to take biopsies if it has not.

Do not skip this appointment, even if you feel completely well.

Duodenal ulcers: no routine re-scope. Cancer in the duodenum is rare, so a duodenal ulcer that responds to treatment does not normally need endoscopic follow-up.

Persistent or recurrent symptoms are investigated instead.

Confirming H. pylori eradication. If you had triple therapy for an ulcer, re-testing with a urea breath test or stool antigen test is recommended.

Timing matters: at least 4 weeks after finishing antibiotics and ideally 2 weeks off the PPI, otherwise the result can be falsely reassuring.

Blood tests. If the ulcer bled or you were anaemic at diagnosis, your GP will usually re-check a full blood count and iron levels once treatment is complete.

What if the ulcer has not healed? Options include extending omeprazole at a higher dose, re-checking for H.

pylori, reviewing hidden NSAID or aspirin use, and biopsy review. Smoking notably slows ulcer healing - stopping is one of the most effective things you can do for yourself.

Ulcers can bleed, perforate or cause obstruction, and these complications can develop even while you are on treatment. Knowing the warning signs matters.

Call 999 or go to A&E immediately if you have:

• vomiting blood - either fresh red blood or material resembling coffee grounds
• black, tarry, foul-smelling stools (melaena), which indicate digested blood
• sudden, severe abdominal pain with a rigid, board-like abdomen - possible perforation
• collapse, cold clammy skin or a racing heart alongside abdominal symptoms

Contact your GP urgently if you notice:

• increasing tiredness, breathlessness on exertion or pale skin - possible anaemia from slow, hidden blood loss
• repeated vomiting, or vomiting food eaten many hours earlier - possible obstruction
• difficulty swallowing, or food sticking on the way down
• unintentional weight loss
• pain that wakes you at night despite taking omeprazole correctly

Iron deficiency anaemia in particular can be the only sign of a slowly bleeding ulcer - there may be no black stools and little pain.

It typically shows up on a blood test as low haemoglobin and low ferritin.

A practical note: if you take aspirin, clopidogrel or an anticoagulant and develop any sign of bleeding, say so immediately when seeking help - it changes both the urgency and the treatment.

Never stop heart medication on your own initiative; that decision belongs with the treating doctor, made quickly but deliberately.