Version July 2025
H2RA: histamine 2 receptor antagonist; H. pylori: Helicobacter pylori; PPI: proton pump inhibitor; TCA: tricyclic antidepressant.
* Testing to diagnose H. pylori infection or confirm eradication after treatment can be performed with a urea breath test, stool antigen testing, or testing of gastric mucosal biopsy specimens obtained during upper gastrointestinal endoscopy. The choice of test depends on the need for an upper endoscopy (eg, follow-up of bleeding peptic ulcer) and local availability. H. pylori serology should not be used to diagnose or confirm eradication of H. pylori. Refer to UpToDate content on the diagnosis of H. pylori for details.
¶ Perform testing to confirm eradication of H. pylori infection 4 weeks after completion of antibiotic therapy.
Δ PPI options include once-daily dexlansoprazole 30 mg, esomeprazole 20 or 40 mg, lansoprazole 15 or 30 mg, omeprazole 20 mg, pantoprazole 20 or 40 mg, or rabeprazole 10 or 20 mg. Patients should take the PPI 30 to 60 minutes before the first meal of the day. H2RAs are an alternative to PPI therapy for patients who are unable to tolerate or prefer not to take a PPI.
◊ In patients with symptom improvement or resolution, we typically continue PPI therapy for 6 months; shorter or longer trials are reasonable. Tapering is not required when treatment duration is short (eg, <6 months). Refer to UpToDate content for details regarding tapering and discontinuing PPIs.
§ In patients with partial response to a PPI, a TCA can be added to PPI therapy.
¥ Starting doses for TCAs include amitriptyline 10 mg, nortriptyline 10 mg, or desipramine 25 mg at night. Doses can be titrated up at 2- to 3-week intervals to a maximum dose of 50 mg nightly.
‡ TCAs are typically tapered over 2 to 4 weeks. Refer to UpToDate content on the discontinuation of TCAs for details.
† In the United States, start metoclopramide 5 to 10 mg 30 minutes before meals and at bedtime. Additional prokinetic agent options are available outside the United States.
