PUD

Question 1

H. pylori treatment begins with

Answer 1

inquire if patient has previous antibiotic exposure

(no 100% cure)

Question 2

H.pylori treatment requires

Answer 2

3 or 4 agents for 10-14 days (acid suppressing, 2-3 antibiotics)

Question 3

1st line treatment options

Answer 3

1. clarithromycin triple
2. bismuth quadruple
3. non-bismuth based quadruple

Question 4

clarithromycin triple therapy is

Answer 4

1. PPI
2. clarithromycin 500mg
3. amoxicillin 1g
   or
   metronidazole 500mg
   all BID

14 days
70-85% eradication

consider in non-penicillin allergy patients with NO previous macrolide exposure

Question 5

bismuth quadruple therapy is

Answer 5

1. PPI (BID)
2. bismuth 120-300mg or bismuth 300mg (QID)
3. metronidazole 250 or 500mg (QID)
4. tetracycline 500mg (QID)

10-14days
75-90% eradication
consider in penicillin allergy pts

Question 6

nonbismuth-based quadruple therapy is

Answer 6

1. PPI (BID)
2. amoxicillin 1g (BID)
3. clarithromycin 500mg (BID)
4. metronidazole 500mg (BID)

10-14 days
90% eradication
(similar to clarithromycin therapy except everything is added; eradication is higher)

Question 7

sequential therapy is

Answer 7

1. PPI (BID) and amoxicillin 1g (BID) then PPI (BID)
2. clarithromycin 500mg(BID)
3. metronidazole 500mg(BID)

5-7, then 5-7days (total 14)
>84% eradication

alternative or salvage therapy

Question 8

hybrid therapy is

Answer 8

PPI(BID) + amoxicillin1g(BID), then:
PPI(BID) +
clarithromycin 500mg(BID)+
amoxicillin 1g(BID)+
metronizadole500mg(BID)

7, then 7days (total: 14d)
88.6% eradication

alternative or salvage therapy

Question 9

levofloxacin-based is

Answer 9

PPI (BID)
levofloxacin 500mg (QD)
amoxicillin 1g (BID)

10-14 days
79-81% eradication

alternative or salvage

Question 10

levofloxacin-sequential is

Answer 10

PPI (BID) + amoxicillin 1g (BID), then: PPI (BID) + levofloxacin 500mg (QD) + metronidazole 500mg (BID)

5-7, then 5-7days (total 14)
83.6-87.4% eradication

Question 11

LOAD therapy is

Answer 11

PPI (double dose QD)
levofloxacin 250mg (QD)
nitazoxadine (Alina)500mg BID
(or metronidazole 500mg BID)
doxycycline 100mg (QD)

Question 12

Peptic ulcer disease (PUD) associated with?

Answer 12

-H.pylori
-NSAIDs
-SRMD (stess-related mucosal damage)

Question 13

prophylaxis candidates for NSAID-induced ulcers

Answer 13

> 60 y.o.
-past hx of PUD or GI events
-high NSAID dosage
-heart disease
-co-prescription of antiplatelets or low dose of aspirin, corticosteroids, and anticoagulants

prolonged NSAID-use
H. pylori infection

Question 14

NSAID-induced ulcer (GU and DU) prevention

Answer 14

misoprostol or PPI

Question 15

NSAID-induced ulcer treatment

Answer 15

-consider stopping NSAID
-eradicate H.pylori if +
-PPI for at least 8wks

Question 16

if NSAID needs to be stopped, what’s the alternative?

Answer 16

sucralfate (for healing only)

Question 17

PUD non-pharmacological interventions

Answer 17

similar to GERD

Question 18

PUD pharmacological interventions

Answer 18

-acid suppression (antacids, H2RAs, PPIs)
-mucosal protection (sucralfate, colloidal bismuth, misoprostol)
-if H.pylori+, tx

Question 19

sucralfate

Answer 19

in acid environment, turns into a viscous, sticky polymer that binds selectively to ulcers and erosions creating a protective barrier

efficacy compared to H2RAs

causes constipation & chelation

Question 20

bismuth

Answer 20

MOA unclear
coats ulcers&erosions, creating a protective layer against acid & pepsin
-may stimulate PF and mucus secretion
-binds bacterial endotoxins=direct antimicrobial activity against H. pylroi

Question 21

misoprostol (Cytotec)

Answer 21

a synthetic prostaglandin that replaces prostaglandins whose production is blocked by ASA or NSAIDs
-stimulates mucus and bicarbonate secretion; promotes mucosal defense
-replaced PG stores
-enhances mucosal blood flow

prevention of NSAID-induced ulcers in high-risk patients

another use is cervical ripening, labor induction in duction in premature rupture of membranes, post-partum hemorrhage

Question 22

H. pylori eradication is standard care in patients with

Answer 22

gastric or duodenal ulcers

Question 23

standard dosages for PPIs

Answer 23

omeprazole 20mg
rabeprazole 20mg
lansoprazole 30mg
pantoprazole 40mg
esomeprazole 40mg

all PO

Question 24

salvage therapy

Answer 24

should include different antibiotics than the initial round

if both clarithromycin & metronidazole used as initial therapy, consider:

amoxicilling 1g BID
levofloxacin 250mg BID
PPI BID

Question 25

consider in penicillin allergic patients who have NOT previously received macrolide or are unable to tolerate bismuth quadruple therapy

Answer 25

standard PPI dose
clarithromycin 500mg
metronidazole 500mg

ALL BID

Question 26

<55y.o. w/ no alarm features, 2 options of treatment are

Answer 26

1. test, treat for H. pylori, trial of acid suppression if eradication is successful but symptoms do not resolve
2. empiric trial of acid suppression w/ PPI for 4-8wk

Question 27

stress-ulcer prophylaxis (SUP) for

Answer 27

1. coagulopathy (platelets <50,000, INR >1,6, or PT>2)
2. mechanical ventilation >48hr
3. hx of GI ulcerations/bleed w/i 1yr before admission
4. head/spinal cord injury
5. burns more than 35% of body surface
6. ICU pts w/ multiple trauma
7. transplant pts:perioperatively
8. at least 2: sepsis, ICU stay >1wk, occult bleeding for at least 6days, use of high-dose corticosteroids (>250mg daily)

Question 28

stress-ulcer treatmetn

Answer 28

no recommendation for PPIs over H2RAs

Question 29

most commonly prescribed SUP

Answer 29

pantoprazole

no comparative data among PPIs to suggest one is superior to another (same for H2RAs)

Question 30

for SUP, if PPI or H2RAs not suitable, consider

Answer 30

sucralfate