64: Peptic Ulcer Disease Flashcards
Peptic Ulcer Disease
-large ulcersthat extend deeper into muscalaris mucosa
-gastric or duodenal
PUD epidemioligy
-lifetime 5-10%
-H. pylori 30-40%
-30-50% of chronic NSAID users
Contibuting factors to PUD
-h. pylori
-NSAID use
-gastric acid + pepsin
-cigs
-critical illness
-dietary factors
PUD pathophysiology
-acid and pepsin overcome mucosal defense
Clinical presentation of h. pylori PUD
-chronic
-duodenum more than tummy
-more dependent on gas pH
-superficial ulcer
-less severe GI bleeding
NSAID and stress PUD clinical presentation
-chronic
-stomach more than duodenum
-less dependent on gas pH
-often asymptomatic
-more severe bleeding
-deep ulcers from NSAIDs
-most superficial ulcers from stress
PUD complications
-GI bleed
-GI perforation
-GI obstruction (life threatenting)
Signs and symptoms of PUD
-epigastric pain
-nausea
-belching, heartburn
-weight loss
-nausea
-bloating
-early satiety
Goals of PUD care
-relieve symptoms
-heal ulcer
-prevent recurrence and complications
-eradicate or withdrawal of offending agent
Non-pharma tx of PUD
-stress reduction
-smoking cessation
-avoid food and drink triggers
-avoid NSAIDs
-surgery
H. Pylori induced PUD
-bacteria bind to wall
-colonize gastric acid
-acid damages tissue and leads to ulcer
H. pylori PUD diagnosis
-endoscopy
-antibody detect
-urea breath test
-fecal antigen
Principles of H. Pylori Tx
-several diff regimens
-usually consist of acid suppressor + 2-3 antibiotics
-helpful to determine if patient has had any recent antibiotic exposure to predict resistance
H. Pylori Tx options
-Bismuth
-Clarithromycin
-Levofloxacin
-Rifabutin
-Vonoprazan
Bismuth salts
-inhibit aggressive factors and inc protective factors
=bacterizidal
-DO NOT USE in kids UNDER 12
Bismuth Quadruple therapy
- PPI BID
- Bismuth 525mg QID
- Metronidazole 250-500mg QID
- Tetracycline 500mg QID
10-14 days
Helidac
-daily admin package
-14 blister cards w metro, terta, and bismuth
-must also take PPI BID
Pylera
-3in1 capsule
-bismuth (140mg), metro, (125mg) tetra (125mg)
-3 caps QID for 10 days
-must take w PPI BID
Clarithromycin Concomitant therapy
- PPI BID
- Clarithromycin 250-500 BID
- Amoxicillin 1g BID
- Metronidazole 250-500mg BID
-10-14 days
Clarithromycin sequentail therapy
PPI and amox the whole time or first half
-add metro and clar for last half
Levofloxacin therapy option
-triple
-quad
-sequential
Levofloxacin trip therapy
- PPI BID
- Levofloxacin 500mg qd
- Amox 1 g BID
-10-14 days
Levofloxacin Quad therapy
- Levo 250mg qd
- Omeprazole or other PPI at high dose qd
- Nitazoxanide 500mg BID
- Doxycycline 100 mg qd
-7-10 days
Levofloxacin Sequential
- PPI BID (day 1-10)
- Amox 1 g BID (day1-5)
- Levo qd (day 6-10)
- Metro BID (day 6-10)
Rifabutin Triple therapy
- omeprazole 40mg q8h
- Amox 1g q8h
- Rifabutin 50mg 18h
-14 days
-no determined place in therapy
Vonoprazan therapy options
-dual
-triple
-potassium-competitive acid blocker
0inhibits H/K ATPase in parietal cells via competitive ANTAgonism of potassium
-onset 2-3 hours
-can also use for erosive GERD
Vonoprazan Dual therapy
- Vonoprazan 20mg BID
- Amoxicillin 1g q8h
-14 days
Vonoprazan triple therapy
- Vonoprazan 20mg BID
- Amoxicillin 1g BID
- Clarithromycin 500mg BID
-14 days
Importance of PPIs in H/ pylori
-antisecretory effects enhance antibiotic acivity
-dec acidity = inc antibiotic
-higher eradication rates
-H2RAs should not be used unless patient cannot tolerate PPI
-PPIs not necessary beyonf 2 weeks of use for eradication
PPI dosing for H. pylori
-Omeprazole 20
-Pantoprazole 40
-Esomeprazole 20-40
-Lansoprazole 30
Probiotics
-potentially used as prophylaxis for H. pylori colonization
-can be taken to supplement antibiotic therapy to inc eradication rates when compared to placebo
-may also reduce effects of therapy
Metronidazole side effects
-acoid alcohol due to disulfram reaction
Clarithromycin side effects
-GI upset
Tetracycline side effects
-photosensitivity
-avoid use in children
Bismuth salts adverse effects
-darkening of stool and tongue
Treatment considerations for H pylori
-avoid antibiotics the pt has already taken
-patient adherence
-consider allergies + intolerances
Facotrs that predict Tx outcomes for H. pylori
-antibiotic resistance
-poor medication adherence
-short duration of therapy
-high bacterial load
PUD treatment failure
-confirmed by diagnostic test 4 weeks after completion of antibiotics and after PPI has been discontinued for 2 weeks
Patients who fail PUD should
-be referred to gastroenterologist
-perform a penicillin skin test if allergy previously listed
If PUD Tx fails,
-select salvage therapy
-chose antibiotics that were not used in previous regimen
-reference specific resistance rates
-use extended treatment duration of 10-14 days
NSAID induced PUD patho
-rule out H. pylori and confirm with endoscopy and low Hgb and Hct if ulcers are bleeding
Patients at high risk for NSAID GI toxicity
-hist of ulcer
-multiple risk factors
Patients at moderate risk for NSAID GI toxicity
-over 65 years old
-high dose NSAID therapy
-previous history of ulcer
-use of aspririn, corticosteroids, anticoagulents
Low risk patients for NSAID GI toxicity
-no risk factors
Prevention of NSAID induced ulcers
-PPI w NSAID
-H2RA w NSAID
-Misoprostol w NSAID
-COX-2 inhibitor
NSAID induced ulcer dosing
ome, panto, esome 40mg qd
-Lansoprazole 30mg
-Famotidine 40 once or 20 BID
-Cimetidine 300 QID, 200 BID, 800 qd
-Misoprostol 200mcg QID w food
Misoprostol for NSAID induced ulcer prevention
-200mcg w food
-prostaglandin E1 analog
-inc mucus and bicarbonate secretion, surface active phospholipids, and gastric blood flow which inhibits secretion
Misoprostol side effects
-diarrhea, ab pain. N/V, headache
-boxed warning abortifacient
-induces labor/abortion
Celecoxib (Celebrex) for NSAID induced ulcer prevention
-selective CoX-2 inhibitor
-anti inflammatory but preserves prostaglandins
-inc CV risk
-prefer Naproxen
NSAID treatment in LOW GI risk and HIGH CV risk
-low dose celecoxib (200mg)
-Naproxen + PPI
NSAID treatment in LOW GI risk and LOW CV risk
-celecoxib
-any ns-NSAID + PPI
NSAID treatment in HIGH GI risk and HIGH CV risk
-low dose celecoxib + PPI
-avoid NSAIDs
NSAID treatment in HIGH GI risk and LOW CV risk
-celecoxib + PPI
NSAID-induced ulcer treatment if patient can stop NSAID
-PPI, H2RA, or sucralfate for 8 weeks
NSAID-induced ulcer treatment if patient can NOT stop using NSAIDs
-PPI for 12 weeks
-lowest effective dose of NSAIDd
-may consider continuing PPI
Sucralfate (Carafate)
-1g QID before meals and at bedtime
-sucrose-sulfate-al complex
-interacts w albumin and fibrinogen = physical barrier over ulcer for protection
Sucralfate (carafate) side effects
-constipation
-metabolic taste
-aliminum toxicity in chronic renal failure
-admin on empty stomach 2 hours before or 4 hours after other medications
