Pharmacy Exam 3: Peptic Ulcers

Front 1

What is the NSAID induced GI bleeding like?

Back 1

more severe, single vessel

Front 2

What is the site of damage for a stress related Mucosal damage?

Back 2

stomach> duodenum
like the NSAID induced

Front 3

What is the intragastric pH like in a stress related mucosal damage?

Back 3

less dependent

Front 4

What symptoms do Stress Related Mucosal Damage have?

Back 4

asymptomatic

Front 5

What are the SRMD ulcer depth like?

Back 5

more superficial

Front 6

What is SRMD GI bleeding like?

Back 6

more severe, superficial mucosal capillaries

Front 7

What are the risk factors for h. pylori induced ulcers?

Back 7

-members of the household with h. pylori infection
-crowded living conditions
-Large number of children (maninly transmitted within families in early childhood)
-Adults with H.pylori infection
-- usually chronic won't heal without treatment
--children can heal spontaneously (probably due to antibiotic use for other conditions)
-Unclean water
-Consumption of raw vegetables

Front 8

JA is a 50 y/o hispanic male that rpesents ot clinic with abdominal pain for 2 weeks. He does not smoke or drink. The pain is relieved with Mylanta. No previous PUD (peptic ulcer disease) history or NSAID use
-CBC is normal
-no blood in stool
BP=120/80
HR= 70
Current Meds- HCTZ 25 mg

Back 8

H.pylori induced ulcer

Front 9

What are the alarm symptoms that require prompt medical attention?

Back 9

-Bleeding
-Anemia
-Early satiety
-Weight loss> 10% of body weight
-Worsening dysphagia/odynophagia
-Persistent vomiting
-Family or personal history of GI cancer
-Previous ulcer
-Lymphadenopathy
-Abdominal mass

Front 10

What are the indications for diagnosis and Treatment of h. pylori?

Back 10

Established
-Active pUD (gastric duodenal ulcer)
-Confirmed history of PUD
-Gastric MALT lymphoma (low grade)
-After endoscopic resection of early gastric cancer
-Univestigated dyspepsia

Front 11

Who should be tested for h.pylori induced ulcers? (guidelines from European H.pylori study group)

Back 11

-PUD
-Low grade MALT lymphoma
-Atrophic gastritis
-First degree relatives of patients with gastric CA
-unexplained iron-deficiency anemia
-Chronic idiopathic thrombocytopenia purpura
-Recurrent abdominal pain in children if otehr causes excluded

Front 12

When do you test and treat h.pylori?

Back 12

-avodis need for scopign
-Will resolve most ulcers (if present)
-If no ulcer present, maybe not much help to test, and expose patient to uncessary Abx
-Test and treat preferable in H. pylori prevalent areas (>10%) or area with high numbers of immigrants

Front 13

What do you do with a positive h.pylori induced ulcer?

Back 13

eradicate (treat)
Retest (Urease breath Test/UBT)- four weeks after completion of treatment (in perfect world)

Front 14

What if you have eradicated but have symptoms of h.pylori?

Back 14

acid supression trial

Front 15

What if h. pylori is not eradicated

Back 15

retreat with different abx

Front 16

What are the tests for h.pylori?

Back 16

Antigen test- serology
frequently done in office; antibody detection

FAT- fecal Antigen Test (stool antigen Test)
-Substrate added to stool-look for color change indicating presence of h.pylori antigen

UBT (Urea breath test)- patients swallow urea labeled with an uncommon isotope. Ten to 30 minutes later the detection of isotope laeled carbon dioxide indicates that urease (enzyme released by h. pylori) is present

Front 17

What are the forms of PUD?

Back 17

-h.pylori
-NSAID induced ulcers
-Stress Ulcers (Stress related mucosal damage)

Front 18

What are the sites of damage for each type of PUD?

Back 18

h.pylori- duodenum>stomach

NSAID induced- stomach>duodenum

SRMD- stomach>duodenum

Front 19

What are the differences in intragastric pH?

Back 19

H.pylori- more dependent

NSAID- less dependent

SRMD- less dependent

Front 20

What are the symptoms like in each of the types of PUD?

Back 20

h.pylori- usually epigastric pain

NSAID induced- often asymptomatic

SRMD- Asymptomatic

Front 21

What are the differences in ulcer depth in PUD?

Back 21

h.pylori- superficial

NSAID induced- deep

SRMD- more superficial

Front 22

What is GI bleeding like in the different PUD?

Back 22

h.pylori- less severe, single vessel

NSAID- more severe, single vessel

SRMD- more severe, superficial mucosal capillaries

Front 23

What should a patient do when the h.pylori test is negative?

Back 23

Patient may have functional dyspepsia (upset stomach or indigestion)

-empiric trail of acid suppression for 4-8 weeks is recommended (h2RA or PPI)
-noresolution after 2-4 weeks, step up therapy if possible (change from h2RA to PPI or increase PpI dosage)
-If symptoms resolve but recur after stopping the 4-8 week trial, provide anotehr trial of same regimen
-Chronic daily therapy may be neede to control symptoms

Front 24

When should empiric Therapy be used for 4-8 weeks?

Back 24

-If symptoms respond, stop the empiric therapy after 4-8 weeks
- if symptoms recur quickly after stopping, perfomr test and treat
-If symptoms don't respond (while on 7-10 days on empiric therapy) perform test and treat

Front 25

What are the empiric Therapy advantages?

Back 25

-If no ulcer is present and the dyspepis is transient (upset stomach is throughout), and expensive workup is saved
-If an ulcer is present, but the 4-8 weeks course heals the ulcer, and there is NO recurrence, an expensive work up is saved

Front 26

What are the disadvantages to empiric therapy disadvantages?

Back 26

-May cuase false negative h.pylori tests if empiric therapy fails
-65-86% of negative ulcer disease patients and 50-80% of h.pylori induced ulcers will have recurrent symptoms within 1-2 years and will get the work up anyway

Front 27

What are PPI, 3 drug regimens for h.pylori eradication?

Back 27

Omeprazole 20 mg BID+ clarithromycin 500 mg BID (drug 2)+Amoxicillin 1 gm BID or Metronidazole 500 BID (drug 3)

Lansoprazole 30 mg BID
Pantoprazole 40 mg BID
Esomeprazole 40 mg QD
Rabeprazole 20 mg BID

Front 28

What are the 4 drug Bismuth based regimens for h.pylori eradication?

Back 28

omeprazole 40 mg BID (drug 1)+ Bismuth subsalicylate 525 QID (Drug 2)+Metro 250 mg-500 mg QID (drug 3)+ Amoxicillin 500 mg QID or Tretracycline 500 mg or Clarithromycin 250- 500 QID- very hard to get)

Lansoprazole 30 mg BID
Pantoprazole 40 mg BID
Esomeprazole 40 mg QD
Rabeprazole 20 mg BID

Front 29

What are the antimicrobials used in h.pylori eradication?

Back 29

-amoxicillin
-Clarithromycin (hard to get)
- Tetracycline
-Metronidazole

Front 30

What are the side effects of Amoxicillin (penicillin)

Back 30

Side effects: nausea, diarrhea, hypersensitivity reactions

Front 31

What are the Side effects of Clarithromycin (macrolide)- increased Resistance (high)?

Back 31

Side effects: HA, diarrhea nausea, dysgeusia (bad taste can last from 6 months), elevated liver enymes hearing loss

Front 32

What are the drug interactions with Clarithromycin (Macrolide)?

Back 32

Theophylline, digoxin, carbamazepine, omeprazole, lovastatin, simvastatin, increased warfarin

Front 33

What are the side effects of tetracycline?

Back 33

Rash, photosensitivity, NVD, tooth discoloration

Front 34

What are the drug interactions with Tetracycline

Back 34

CA/Mg/Alum containing antacids, iron salts, decrease TCN absorption; warfarin effect increased

Front 35

What are the side effects of Metronidazole?

Back 35

dizziness, rash, disulfram-type reaction with alcohol, metallic taste

Front 36

What are the drug interactions of metronidazole?

Back 36

Disulfram (psychotic episodes); rifampin and phenobarbital may increase metabolism of metronidazole,; increased levels of phenytoin, lithium, warfarin

Blocks oxidation of alcohol at acetaldehyde stage- HA, NVD, hallucination

Front 37

What do people do if they are allergic to penicillin?

Back 37

-No amoxicillin
-Clarithromycin+Metrondazole (use this instead)
-Can add bismuth

Front 38

What is the mainstay therapy for h.pylori induced ulcers?

Back 38

3 drug PPI regimen, however 4 drug bismuth-containing regimens are anotehr 1st line tx
-Most regimens are 10-14 days
-14 days is prudent to make every opportunity to optimize treatment success
-an h2RA can be substituted for a PPI if PPI isn't tolerated

Resistance
- clarithromycin resistance is rising (20%)
-Metronidazole resistance is higher (42%)

Front 39

What if regimen fails for 3 day drug PPI Regimen?

Back 39

1. first line: 3 drug PPI; if it fails then see #2
2. Retreat with 3 drug regimen and different Abx
-- or a 4 drug bismuth based regimen with metronidazole, tetracycline, and a PPI

Other options:
Levofloxacin, 500 mg qd/PPI/Amoxicillin 1 gm BID for 10 days has shown an eradication rate of 87% (studies done ouside of US)

Front 40

What are the prepackaged formulations?

Back 40

Prevpac: 14 day supply of lansoprazole 30 mg, clarithromycin 500 mg and amoxicillin 1000 mg dosed twice a day
helidac Pack- bismuth subsalicylate 525 mg, metronidazole 250 mg, tetracycline 500 mg, plus a PPI
Pylera Capsule- bismuth subcitrate 140 mg, metronidazole 125 mg, tetracycline 125 mg. Note: 3 capsules per dose

Front 41

What is the sequential therapy

Back 41

10 days total: - 5 day course of PPI+ BID with Amoxicillin 100 mg BID
immediately followed by a second course of
- clarithromycin (liquid) 500 mg BID, metronidazole BID and a PPI BID for 5 days

cure rate 92% in Europe

Front 42

What can you do if symptoms persist beyond 1-2 weeks of treatment?

Back 42

You can extend the acid suppression component to a total of 8 weeks (for duodenal ulcer) or 12 weeks (for gastric ulcer)

Follow up scope should be done to confirm healing and eradication

High dose PPIs may be needed to heal a refractory ulcer

Front 43

What are the reasons for refractory ulcers?

Back 43

Refractory ulcers- Sx, ulcers or both that persist beyond 8 weeks (duodenal) or 12 weeks (gastric) despite conventiaonal therapy or when several courses of h. pylori eradication fail
- poor patient compliance
-Antimicrobial resistance
-cigarette smoking
-NSAId use
-Gastric acid hyper-secretion
-Tolerance to effects of h2RA

Front 44

NSAID induced ulcers are more prevalent in what gender?

Back 44

prevalence is shifting to both genders

Front 45

What are the trends for NSAID induced ulcers?

Back 45

recent trends suggest a declining rate for younger men and increaseing rate for older women

Front 46

What are the factors that have influenced the trends in NSAID induced ulcers?

Back 46

declining smoking rates in younger men and increased use of NSAIDS in older adults

Front 47

What are the risk factors for NSAID factors?

Back 47

Age over 60 y/o
Previous PUD
Previous GI bleed
Concomitant corticosteroid therapy- alone is not a risk factor but is w/ a NSAID
High dose and multiple NSAID use (watch OTC's)
Concomitant anticoagulant use or coagulopathy
Chronic major organ impairment (Cardiovascular disease)

Front 48

What does Cox1 do?

Back 48

affects integrity of mucosa, affects the stuff that produces protective prostaglandins

Front 49

What are non-selective (traditional ) NSAIDS

Back 49

Idomethacin, piroxicam, ibuprofen, naproxen, sulindac, ketoprofen, ketolorac, fluribprofen, diclofenac

Front 50

What are the partially selective NSAIDs?

Back 50

Etodolac nabumetone, meloxicam

-decreased incidence of GI toxicity

Front 51

What are the selective COX-2 inhibitors

Back 51

celecoxib, valdecoxib

decreased incidence of gastroduodenalulcers and related GI complications

COX2 inhibitors are associated with MI

Front 52

What are salicylates and what does it do?

Back 52

acetylated: aspirin
Aspirin irreversibly inhibits platelet COX 1 for as long as 18 hours, resulting in decreased platelet aggregation and increased bleeding time

nonacetylated- decrased incidence of GI toxicity; salsalate, trisalicylate

Front 53

What is the clinical presentation of NSAID induced PUD?

Back 53

mild epigastric pain to acute life threatening GI complications

N&V, anorexia

Weight loss
Complication from ulcer bleeding
-perforation, penetration, obstruction

Front 54

What are the tests for NSAID induced PUD?

Back 54

hemoglobin/hematocrit, hemoccult, endoscopy

Front 55

What are the non pharmacologic therapy for PUD?

Back 55

-smoking cessation
-Stop NSAIDS & ASA, if possible use agents such as acetaminophen, non-acetylated salicylate, or cox 2 inhibitors for pain
-Avoid spicy foods that exacerrbate ulcer symptoms
-Surgery not common anymore, may be required to stop a bleed, perforation, or obstruction

Front 56

What are the pharmacologic Treatment

Back 56

Patients with NSAIDS induced ulcers should be tested for h. pylori status, and treated if positive
-If h.pylori negative, NSAID should be stopped
-If NSAID must be continued, treat with a PPI or misoprostol
--PPI drug of choice when NSAID must be continued *

-Can also change put NSAID to COX2 inhibitor and add PPI for a high risk patient

Front 57

What are the Proton Pump Inhibitors used for?

Back 57

To heal or maintain ulcer healing

Front 58

What is dose for PPI?

Back 58

omeprazole 20-40 mg daily
Lansoprazole 15-30 mg daily
Rabeprazole 20 mg daily
Pantoprazole 40 mg daily
Esomeprazole 20-40 mg daily

Maintenance dose is same as healing dose

Front 59

H2RA is used for what?

Back 59

heal or maintain ulcer healing

Front 60

What are the doses for H2RA drugs?

Back 60

nizatidine healing
150 mg BID
300 mg QHS

Maintenance
150 mg to 300 mg QHS

NSAIDS must be stopped for thearpy (6-8 weeks)

Ranitidine is the same as nizatidine
Cimetidine not a good drug
Famotidine 20 mg BID or 40 mg QHS

Front 61

What is sucralfate used for?

Back 61

used to promote mucosal defense

Front 62

What is the dose for sucralfate?

Back 62

dose to treat duodenal or gastric ulcer- 1 gm QID (4x) or 2 gm BID

maintenance dose- 1-2 gm BID or 1 gm QID

Front 63

What is the MOA for Sucralfate?

Back 63

MOA: forms a complex, paste like substance that adheres ot site of damaged mucosal area and protects it from acid, bile, and pepsin

Front 64

When should sucralfate be taken? What are deterrants to use?

Back 64

should be taken on an empty stomach to prevent binding to dietary protein and phsophate

Deterrents: multiple doses, large tablet size, need to separate from meals, drug interactons

Front 65

What are side effects of sucralfate?

Back 65

nausea, metallic taste, dry mouth

Front 66

What are the drug interacdtions with sucralfate?

Back 66

reduces bioavailability of oral fluoroquinolones, phenytoin, digoxin, warfarin, theophylline, ketoconazole

Front 67

What is the drug of choice according to guidelines for prophylaxis

Back 67

Mioprostol (cytotec)
200 mcg QID reduces the risk of NSAID induced gastric ulcer, duodenal ulcer and ulcer related GI

Diarrhea and abdominal cramping limit its use can be dosed down to 200 mcg TID for better tolerance
-less than 400 mcg/day compromise efficacy

Front 68

What is MOA for misoprostol?

Back 68

replaces the protective prostaglandins consumed with prostaglandin inhibiting therapies (NSAIDS) resulting in reduction of acid secretion from the gastric parietal cell and stimulation of bicarbonate production fromt eh gastric and duodenal mucosa

Front 69

What are the side effects of misoprostol?

Back 69

HA, NVD, constipation, flatulence, GI pain, uterine stimulation, cramps, vaginal bleeding, uterine rupture*, anemia, tinnitis, earache

Front 70

What are the drug interactions of misoprostol?

Back 70

mg containing antacids enhance diarrhea associated with misoprostol

Front 71

T/F Misoprostol is not as efficacious as omeprazole

Back 71

False, it is shown to be as efficacious as omeprazole in one trial in healing ulcers

Front 72

Why is misoprostol not a guideline choice for healing?

Back 72

due to lack of clinical superiority and poor tolerability, it is used for prophalaxis

Front 73

What do you do if there is dyspepsia on NSAID?

Back 73

stop NSAID if possible or change to lower dose or selective NSAID/Cox-2 inhibitor

Front 74

If you can not stop NSAID, what can you use?

Back 74

use PPI vs. H2RA
-consider h.pylori test and treat

Front 75

What are the risk factors that should be reviewed?

Back 75

Age
Previous PUD/GI event
NSAID use

Front 76

What is h.pylori?

Back 76

an infectious disease that can be eradicated with antimicrobial therapy

Front 77

How should you select a treatment for patients with h.pylori?

Back 77

patients shoudl be treated with elast expensive, most effective, and safest regimen

Front 78

When shoudl retesting happen?

Back 78

Should be done at least 4 weeks after treatmetn

Front 79

T/F patients can be re-infected

Back 79

True