A 54-year-old man presents with gnawing epigastric pain that occurs at regular intervals daily. The pain is paially relieved by antacids and food. Upper endoscopic studies reveal a duodenal lesion. Fuhermore, a biopsy confirms the benign nature of the lesion and demonstrates numerous Helicobacter pylori bacilli. Which of the following would be the most effective pharmacotherapy?

The gross specimen shows a typical peptic ulcer of the first poion of the duodenum. The great majority of these ulcers are associated with chronic H. pylori infection, which plays a pathogenetic role. Eradication of H. pylori is necessary not only for rapid healing of active ulcers, but also to prevent future recurrence. Therefore, drugs that eradicate this gram-negative bacillus are used for treatment of active peptic ulcer disease. Proton pump inhibitors (omeprazole or lansoprazole) also have activity against H. pylori, but alone are not sufficient to achieve eradication. This treatment must be combined with at least one of the antibiotics (usually two) that are effective against H. pylori. Clarithromycin is usually used in combination with either metronidazole or amoxicillin. Aluminum or magnesium-containing antacids are probably the most common over-the-counter medications used by patients with peptic ulcers and gastroesophageal reflux for prompt relief of epigastric pain and discomfo. These drugs are no longer recommended as first-line agents for treatment of peptic disease nor do they have anti-H. pylori activity. H2-receptor blocking agents, including cimetidine, famotidine, and ranitidine are not effective in eradicating H. pylori infection. However, they provide rapid symptomatic relief and promote ulcer healing. Prostaglandin analogs (e.g. misoprostol) are used exclusively as prophylactic agents to prevent NSAIDs-induced ulcers, not as a standard treatment of peptic ulcers. These drugs act by stimulating mucus and bicarbonate production.