Module 2: NSAID and PUD Covert

Question 1

Where do Peptic ulcers occur?

Answer 1

-Stomach or Duodenum

Question 2

Pathophysiology of PUD

Answer 2

-caused by an imbalance between protective factors and destructive (damaging) factors

Question 3

What are the protective and destructive factors

Answer 3

Protective:
-Mucous/Bicarb lining
-Prostaglandins (PGs) - inhibited by NSAIDs, PGs
-Mucosal blood flow

destructive:
-HCl
-Pepsin
-EtOH
-Bile salts
-Drugs

Question 4

How do prostaglandines help protect the mucosal lining?

Answer 4

-increase the thickness of mucous and bicarb lining -increases mucosal blood flow

Question 5

NSAID and ASA-induced PUD

Answer 5

-direct mucosal irritant
-reduction in mucosal protection

Question 6

Which type of COX has actions on the stomach (also kidney, platelets, intestinal endothelium)?

Answer 6

COX-1 (always expressed)
-> responsible for Prostaglandine production (important for mucosal protection) !!!

-inhibited by NSAIDs and ASA
so choose a selective COX-2 inhibitor

Question 7

Risk factors for PUD?

Answer 7

-Age > 65
-previous PUD
-High-dose or multiple dose of NSAIDs
-non-selective NSAIDs
-H. pylori
-EtOH
-smoking

Meds:
-Bisphosphonates
-Corticosteroids (thin out the lining)
-Anticoagulant, Antiplatelets (risk of ulcer bleeding)
-SSRIs (can make an ulcer more likely to bleed)

Question 8

What are the Non-selective COX inhibitors?
NSAIDs

Answer 8

-high GI risk: inhibit prostaglandins (protective factor)

-Ibuprofen
-Naproxen
-Ketorolac (Rx)

Question 9

What are the partial-selective COX inhibitors?
NSAIDs

Answer 9

-bind more to COX-2 than COX-1 -> lower GI risk

-Etodolac
-Meloxicam
-Celecoxib
-Diclofenac

Question 10

Which Salicylates have a higher risk for GI issues?

Answer 10

-High GI risk:
Acetylated (ASA)

-lower risk:
Non-Acetylated: Salsalate, Trisalicylate (not often used)

Question 11

How to treat PUD with no bleeding Ulcer?

Answer 11

-NSAID/ASA can be DC
Do symptoms resolve? -> no treatment
Still having symptoms ->daily PPI for 4 weeks

-NSAID/ASA can’t be DC (recent stroke, heart attack)
if the problem is caused by NSAID
choose COX-2 selective NSAID (if possible) + daily PPI for 8-12 weeks

Question 12

What are prophylactic treatment options for patients at higher risk for CV issues?

Answer 12

-if high CV risk: keep ASA and add PPI or misoprostol

-if high GI risk -> avoid NSAIDs if possible, or choose partially/COX-2 selective NSAID + PPI/misoprostol

Question 13

What determines the state of GI risk?

Answer 13

-Age over 65
-number of risk factors (H. pylori, smoking, alcohol, meds (SSRI, bisphosphonate)
-use of ASA, steroids, anticoagulants, dual antiplatelet therapy (DAPT)
-prior ulcer

Question 14

What are the prophylactic drugs to prevent NSAIDS/ASA-induced PUD?

Answer 14

-PPIs: preferred due to side effect profile, but need to taper to DC

-Prostaglandine analogs:
Misoprostol 200 mcg PO 4x daily
Arthrotec (misoprostol 200 mcg/diclofenac 50mg) - protection from diclofenac
Abortifacient