Peptic Ulceration with NSAID Use

Question 1

Risk factors of peptic ulcers in general

Answer 1

1. H pylori +ve
2. > 60 yo
3. Increase NSAID use
4. PMHx of Peptic ulcer disease
5. Concurrent: glucocorticoids, anticoagulants, bisphosphanates, aspirin

Question 2

Non-drug management of PU with NSAID use

Answer 2

• Cease NSAIDs
• Cease smoking
• Decrease spicy food intake
• Decrease caffeine intake

Question 3

Short term management goals of PU with NSAID use

Answer 3

1. Treat or heal ulcer
2. Prevent complications
3. Remove cause (e.g. NSAIDs)
4. Prevent ulceration if NSAIDs are required with PPI or misoprostol (prostaglandin analogue)

Question 4

List the 6 main drug treatments for dyspepsia, reflux and peptic ulcer

Answer 4

1. Antacid
2. Cytoprotective agent
3. H pylori eradication
4. H2 antagonist
5. Prostaglandin analogue
6. PPIs

Question 5

What is the main antacid used?

Answer 5

Aluminium Hydroxide

Question 6

In what situations are antacids used?

Answer 6

Only promotes symptomatic relief and does NOT speed up healing

Question 7

What is the main cytoprotective agent used?

Answer 7

Sulcralfate

Question 8

In what situations are cytoprotective agents used?

Answer 8

It is used mainly in ICU to prevent stress ulcers in patients

Question 9

What Abx are used for H pylori eradication?

Answer 9

2/3 combinations of amoxycillin, metronidazole or clarithromycin
PLUS a PPI

Question 10

What are the names of the main H2 antagonists used?

Answer 10

Cimetidine and ranitidine

Question 11

Why are H2 antagonists not the first line in promoting ulcer healing?

Answer 11

Although they promote healing, they are not as effective

Question 12

What is the main prostaglandin analogue used?

Answer 12

Misoprostol

Question 13

In what situations are prostaglandin analogues used?

Answer 13

The main use of prostaglandins is prophylaxis against NSAID-induced peptic ulcers (not as efffective in H pylori associated ones)

Question 14

What are the main AFx of prostaglandin analogues?

Answer 14

• May induce premature labour (abortifacient)

- GI: abdo pain, loose stools, diarrhoea

Question 15

What are the names of the main PPIs used?

Answer 15

“-prazole”

Question 16

In what situations are PPIs used in?

Answer 16

To prevent reflux oesophagitis, ulcer healing and NSAID ulcer prevention
NB: In NSAID ulcer prevention as co-therapy, it decreases the risk by 60%

Question 17

Which drug class is first line as co-therapy with NSAIDs in high PU risk patients?

Answer 17

PPIs are first line, then misprostol (prostaglandin antagonist)

Question 18

If a patient is in risk of developing a PU due to NSAIDs, why is a PPI + NSAID preferred over a COX-2 selective NSAID?

Answer 18

PPI + NSAID is just as effective as a COX-2 selective.

COX-2 also has CVD complications and is more expensive

Question 19

What should occur in post treatment monitoring?

Answer 19

1. Take Hx and exam to determine progression of Sx
2. Ask about adherence to Rx (side effects) - Rx must be taken 4-6 weeks after Sx resolved
   NB: no further endoscopy required if asymptomatic from Hx

Question 20

What are the long term complications of PPI treatment?

Answer 20

1. Increase risk of fractures
2. Interstitial nephritis
3. C difficile infection
4. Aspiration pneumonia

Question 21

What steps should be taken immediately in the setting of an acute PU bleed due to NSAIDs?

Answer 21

Stop NSAID use and IV PPI