Ex.6 PUD (64) Flashcards
Peptic Ulcer Disease
Large Ulcers (greater than or equal to 5 mm) and extend deeper into the muscularis mucosa
-Types of ulcers: gastric, duodenal
Epidemiology
-Lifetime prevalence is between 5-10% in the US
-H. Pylori prevalence is 30-40%
-PUD is prevalent among 30-50% of chronic NSAID users
Contributing Factors
H. Pylori infection
NSAID use
Gastric acid + Pepsin
Cigarette smoking
Critical illness
Dietary Factors
Pathophysiology
Aggressive factors (gastric acid and pepsin) overcome protective factors (mucosal defense and repair)
Life threatening Complications:
GI Bleed
GI Perforation
GI obstruction
Signs and symptoms
Epigastric pain
Nausea
Belching, heartburn
Bloating, Abdominal fullness
Weight loss
Early satiety
Goals of Care
Relieve ulcer symptoms
Heal the ulcer
Prevent recurrence and complications
Eradicate or withdrawal of offending agent
Non-Pharmacologic Therapy
Stress reduction
Smoking cessation
Avoid food and drink triggers
Avoid NSAIDs
Surgery
H. Pylori induced Pathophysiology + Diagnosis
Pathophysiology
-Bacteria bind to the epithelial wall and colonize gastric acid
-Gastric acid damages tissue and leads to ulcer
Diagnosis:
-endoscopy
-Antibody detect
-Urea breath test
-Fecal antigen
Principles of H. Pylori Tx
Several different tx. regimen options
Typically consists of acid suppressor + 2-3 antibiotics
Helpful to determine if patient has had any recent antibiotic exposure to predict resistance
Therapy Overview
Bismuth
-Quad therapy
Clarithromycin:
-Triple therapy
-Concomitant therapy
-Sequential therapy
-Hybrid therapy
Levofloxacin
-Triple therapy
-Quad therapy (LOAD)
-Sequential therapy
Rifabutin
-Triple therapy
Vonoprazan
-Dual therapy
-Triple therapy
Bismuth - Quad therapy
Bismuth salts
-Topical bactericidal effect by inhibiting aggressive factors and increasing protective factors
AVOID salicyclate products in children <12 years old due to risk of Reye’s syndrome
Contains:
1. PPI BID
2. Bismuth subsalicyclate 525mg QID
3. Metronidazole 250-500mg QID
4. Tetracycline 500mg QID
10-14 days
PREFERRED REGIMEN
Convenience packaging for H. Pylori - Helidac
Helidac
-Daily admin package
-“Bismuth quadruple”
-14 blister cards containing:
-Metronidazole 250mg (i tab QID)
-Tetracycline 500mg (1 tab QID)
-Bismuth subsalicyclate 262.4mg (2 tabs QID)
-Must also take PPI BID
Convenience packaging for H Pylori - Pylera
3-in-1 capsule containing:
-Bismuth subcitrate potassium 140mg
-Metronidazole 125mg
-Tetracycline 125 mg
Dose: 3 caps QID for 10 days
Must also take PPI BID
Bismuth quadruple
Therapy overview: Clarithromycin Triple therapy and concomitant therapy
Triple:
1. PPI BID
2. Clarithromycin 500mg BID
3. Amoxicillin 1G BID OR Metronidazole 500mg BID
*14 days
Note: Triple therapy is no longer recommended in the US due to macrolide resistance
Concomitant:
1. PPI BId
2. Clarithromycin 250-500mg BID
3. Amoxicillin 1G BID
4. Metronidazole 250-500mg BID
*10-14 days
Note: Concomitant or “Non-Bismuth Quad” is also another first line therapy
Clarithromycin Sequential and hybrid Therapy
Sequential:
1. PPI BID (days 1-10)
2. Amoxicillin 1G BID (days 1-5)
3. Metronidazole 250-500mg BID (days 6-10)
4. Clarithromycin 250-500mg BID (days 6-10)
*10 days
Hybrid:
1. PPI BID (days 1-14)
2. Amoxicillin 1G BID (days 1-14)
3. Metronidazole 250-500mg BID (days 7-14)
4. Clarithromycin 350-500mg BID (days 7-14)
*14 days
Levofloxacin therapies
Triple Therapy
1. PPI BID
2. Levo 500mg daily
3. Amoxil 1G BID
*10-14 days
Quad therapy (LOAD)
1.Levo 250mg daily
2. Omeprazole (or other PPI) at high dose once daily
3. Nitazoxandine 500mg BID
4. Doxycycline 100mg Daily
*7-10 days
Sequential
1. PPI BID (days 1-10)
2. Amoxil 1G BID (days 1-5)
3. Levo 500mg daily (days 6-10)
4. Metro 500mg BID (days 6-10)
*10 days
Rfabutin - Triple Therapy
- Omeprazole 40mg Q8H
- Amoxil 1G Q8h
- Rifabutin 50mg 18H
*14 days
No determined place in therapy, typically used as a salvage therapy currently
Vonoprazan therapy
Potassium-Competitive Acid Blocker
-Inhibits H/K ATPase in parietal cells via competitive antagonist of potassium
Onset
2-3 hours
Indications
PUD and Erosive GERD
Vonoprazan Dual and triple therapy
Dual:
1. Vono 20mg BID
2. Amoxil 1G Q8H
*14 days
Triple:
1. Vono 20mg BID
2. Amoxil 1G BID
3. Clarithromycin 500mg BID
*14 days
Importance of PPIs in H. Pylori
BID PPIs are the backbone of tx
Antisecretory effects from PPIs enhance antibiotic activity
-PPIs have been shown to produce higher eradication rates
-H2RAs should not be used unless patient cannot tolerate PPI
PPIs usually not necessary beyond 2 weeks of use for eradication
Decrease in acidity, increase in antibiotic concentration
PPI dosing H pylori
Omeprazole(Prilosec):
20mg
Pantoprazole (Protonix):
40mg
Esomeprazole (Nexium):
20-40mg
Lansoprazole (Prevacid)
30mg
Probiotics
Could potentially be used as prophylaxis for H. Pylori colonization
Can be taken to supplement antibiotic therapy to increase eradication rates when compared to placebo
-May also reduce adverse effects of therapy
Adverse effects probiotics
Metronidazole
-Avoid alcohol due to disulfiram-like rxn
Clarithromycin
-GI upset (N/V/D)
Tetracycline
-Photosensitivity
-Avoid use in children
Bismuth Salts
-Darkening of stool and tongue
Treatment considerations: Probiotics
Avoid antibiotics the patient has already taken
Patient adherence
Consider allergies + intolerances
Factors that predict treatment outcomes
Antibiotic resistance
Poor medication adherence
Short duration of therapy
High bacterial load
Treatment Failure
Confirmed by diagnostic test 4 weeks after completion of antibiotics and after PPI has been d/c for 2 weeks
Patients who failed tx should:
-Be referred to gastroenterologist
-Perform a penicillin skin test if allergy previously listed
Treatment failure: selecting salvage therapy
Chose antibiotics that were not used in previous regimen
Reference local or institution specific resistance rates
Use an extended tx. duration of 10-14 days
NSAID Induced PUD pathophysiology
Rule out H. Pylori and confirm with
-Endoscopy
-Low Hgb and Hct if ulcers are bleeding
Patients at diff levels of risk for NSAID GI toxicity
High Risk
-History of a previously complicated ulcer, especially recent
-Multiple (>2) risk factors
Moderate risk (1-2 factors)
-Age >65 years
-High dose NSAID therapy
-A previous hx of uncomplicated ulcer
-Concurrent use of aspirin (including low dose) corticosteroids or anticoagulants
Low risk
-No risk factors
Prevention of NSAID induced PUD
PPI
H2RA
Misoprostol
COX-2 Inhibitor (admin with NSAID)
Misoprostol (Cytotec)
Dosing:
200mcg QID with food
MOA:
-Prostaglandin E1 analog
-Increased mucus and bicarbonate secretion
-Increased surface active phospholipids
-Increased gastric mucosal blood flow inhibits acid secretion
SE: N/V/D, abdominal cramping, flatulence, HA
BOXED WARNING
-Pregnancy category X: induces labor or abortion
-MUST CONFIRM patient is not pregnant in women of child-bearing age
Celecoxib (Celebrex)
MOA: selective inhibition of COX-2
Equivalent anti-inflammatory effects but preserves prostaglandins
BOXED WARNING
Increased risk of CV events
Naproxen is the preferred non-selective agent due to decreased CV risk
Treatment: Sucralfate (Carafate)
Dosing:
1g QID before meals and at bedtime
MOA: sucrose-sulfate-aluminum complex that interacts with albumin and fibrinogen to form a physical barrier over an open ulcer -> protects ulcer to allow it to heal
SE:
Constipation, metallic taste, aluminum toxicity in chronic renal failure
Counseling:
-Admin on empty stomach 2 hours before or 4 hours after other medications
Tx of NSAID induced PUD
If patient can stop NSAID:
-PPI, H2RA or sucralfate for 8 weeks
If patient is continuing NSAID:
-PPI for 12 weeks
-Use lowest effective dose NSAID
-May consider continuing PPI
