A 48-year-old woman is diagnosed with a duodenal ulcer complicated by Helicobacter pylori infection. After eradication therapy, she develops a recurrent ulcer. Which drug is the preferred choice for long-term maintenance therapy to prevent relapse?

Explanation

## Maintenance Therapy for Peptic Ulcer Disease Post-H. pylori Eradication **Key Point:** After successful H. pylori eradication, long-term acid suppression with a PPI is the standard maintenance regimen to prevent ulcer recurrence. ### Pathophysiology of Recurrent Ulcer Following H. pylori eradication, recurrent ulcers in the duodenum typically result from: - Incomplete eradication of the organism - Non-adherence to eradication therapy - Continued NSAID use (if applicable) - Persistent acid hypersecretion **High-Yield:** Maintenance acid suppression with a PPI (half the acute treatment dose) is recommended for 6–12 months post-eradication to allow complete mucosal healing and prevent relapse. ### Comparison of Agents for Maintenance Therapy | Agent | Class | Efficacy for Maintenance | Duration | Typical Dose | |---|---|---|---|---| | **Lansoprazole** | PPI | ✓✓✓ (>95% healing) | 24 hours | 15 mg once daily | | **Famotidine** | H₂ blocker | ✓✓ (70–80% healing) | 12 hours | 20 mg once daily | | **Magnesium trisilicate** | Antacid | ✗ (no acid suppression) | 30–60 min | Not suitable | | **Bismuth subsalicylate** | Antimicrobial adjunct | ✗ (not for maintenance) | — | Used only during eradication | **Clinical Pearl:** Lansoprazole (or any PPI) is superior to H₂ blockers for maintenance because it achieves durable acid suppression and allows complete mucosal regeneration. H₂ blockers are less potent and require twice-daily dosing for equivalent effect. **Warning:** Antacids and bismuth salts are NOT suitable for long-term maintenance — they provide only temporary relief or are used only during eradication therapy. ### Evidence-Based Recommendation ACG and international guidelines recommend: - **Post-eradication maintenance:** PPI at half the acute dose (e.g., lansoprazole 15 mg once daily) for 6–12 months - **Monitoring:** Confirm H. pylori eradication with urea breath test or stool antigen test 4 weeks after therapy - **NSAID avoidance:** Critical to prevent recurrence [cite:Harrison 21e Ch 297]