Petic Ulcer Disease PUD √ Flashcards
State the 5 alarm symptoms
- Bleeding in stool or anemia
- Unexpected weight loss
- Dysphagia D for difficulty
- Odynophagia O for ouch
- Vomiting
What are the 3 most common cause for PUD
H. Pylori
NSAID use
Stress
What pts do you test for H. Pylori
1.Active/symptomatic PUD
2. PMH PUD (unless previous H. pylori cure was attained)
3. Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma
4. History of endoscopic resection of early gastric cancer
5. Long-term, low-dose ASA (to reduce ulcer bleed risk)
6. Initiating chronic NSAID therapy
7. Patients with + dyspepsia, <60 yrs, and no alarm features
What pt do we not test for H. Pylori
GERD with no PMH PUD
What are the difference from GERD and H. Pylori
- “maybe” location of pain
- Duration of symptoms (> 3 months)
- Symptoms still present after taking H2RA or PPI
- Presence of alarm symptoms
- Exclusions for self-treatment
4 Testing for H. Pylori
- Urea breath test (BreathIDTM)
- Fecal antigen test
- Antibody testing
- PCR
What constitutes cure of H. Pylori
No detection 4 week post therapy and 1-2 weeks after PPI stopped
Non pharm treatment for H. Pylori
Avoid smoking
Avoid trigger foods
Refrain from eating 2-3 hours of lying down (sleep on left side)
GERD Pillow
Weight loss
What 2 questions do we consider before starting H. Pylori treatment
- True penicillin allergy
- Is patient treatment Naive
What are the 4 first-line therapy options
- Bismuth quad - please make tummy better
- Rifabutin triple
- Vonoprazan or PCAB dual
- Vonoprazan or PCAB triple
What treatment is “ Please make tummy better”
Bismuth quad
PPI (Please) + metronidazole (make) + tetracycline (tummy) +bismuth sub (better)
What is the treatment Rifabutin triple
omeprazole, amoxicillin, rifabutin
What is the treatment Vonoprazan or PCAB dual
vonoprazan and amoxicillin
What is the treatment Vonoprazan or PCAB triple
vonoprazan, amoxicillin, and clarithromycin
What therapy is your salvage therapy for H. Pylori
What are two consulting points of Vonoprazan?
- no need to take with food
- less GI AD
Treatment decision tree
Which PPI has the most and least CYP interaction
Omeprazole and esomeptazole MOST
Rabeprazole - Least
What do we need to tell the patient if we give them Pylera?
need to take 4 times a day and doesn’t include omeprazole
only 10 day regiment too (best 14)
What do we need to tell the patient if we give them Helidac?
only FDA approves if added with H2RA (but this isn’t recommended anymore)
What do you consider when taking a salvage option for H. Pylori
Do not use what was in the previous regiment
PPI standard dosing
What drugs are strong CYP inhibitors
ketoconazole, itraconazole, cimetidine, GFJ, erythromycin, clarithromycin
What drugs are strong CYP inducers
rifampin, carbamazepine, St John’s wort
If the patient is on atorvastatin, what do we need to monitor?
Monitor for muscle pain/weakness (due to atorvastatin CYP3A inhibition)
AD of Bismuth Quad
Name 3 salvage therapies besides B quad and Rifabutin triple
Can I repeat bismuth Quad if it wasnt optimized and they still have H. Pylori
Yes
If patient is a chronic drinker what medication should we avoid
Metronidazole
What is the indication and medications in Talicia
FOR treatment naive/ empric
Omeprazole 40 mg THREE TIMES DAILY
Rifabutin 50 mg TID
Amoxicillin 1000 mg BID
What is the indication and medications for non-Talicia
Salvage/ treatment experienced
PPI standard or double dose TWICE DAILY
* Rifabutin 50 mg TID or 150 mg BID
* Amoxicillin 1000 mg BID or TID
