PUD Flashcards
- What are the 2 types of peptic ulcers?
- Describe the characteristics of each type
- gastric and duodenal
- Gastric : pain w/food, nausea, weight loss
Duodenal : pain relieved with food, pain after 1.5-3 hr after food, nocturnal awakening with pain, weight gain
State the ALARM sx’s of PUD (5)
- bleeding (hematemesis, dark stools/melena, occult bleeding, anemia)
- unexplained weight loss
- dysphagia
- odynophagia
- vomiting
What about some most common sx’s?
Labs expected?
epigastric pain, abdominal pain, nocturnal pain
burning, cramping and fullness -discomfort
heartburn,belching, bloating
Low Hct, low Hgb + stool hemoccult test
How to differ GERD/heartburn from PUD as signs or sx’s of overlap? (5)
How to concretely differ/diagnose PUD?
- Maybe location of pain
- duration of sx’s > 3 months
-sx’s still present after taking H2RA or PPI
-Presence of alarm sx’s
-Exclusions for self tx - Endoscopy or test for H pylori
What are the 3 most common PUD etiologies?
H pylori infection (~70% of all PUD diagnoses) high risk groups such as those born outside USA
NSAID Use
Stress (from critical illness resulting in mucosal damage/bleeding)
PUD Diagnosis using any of the following methods?
- endoscopy
- H.Pylori Testing (urea breath test, fecal antigen test, antibody testing, PCR)
Which pt’s do you test for H Pylori?
- All pt’s with? (4)
- Testing is not recc in which pt’s?
- Consider testing in pt’s? (3)
- -active/symptomatic PUD,
-PMH PUD (unless previous H.Pylori cure was attained),
-low grade gastric mucosa-associated lymphoid tissue lymphoma (MALT)
-History of endoscopic resection of early gastric cancer - pt’s with GERD with no PMH of PUD
- Long term, low dose ASA (to reduce ulcer bleed risk)
-initiating chronic NSAID therapy
- dyspepsia but <60 yrs and no alarm features
For 1st line therapy for HPylori PUD what are the 2 key questions to always consider?
Is there a PCN allergy?
Has the pt previously taken any macrolide (azithro, clarithro, erythro) for any reason? or is the clarithromycin resistance >15%?
- Risk Factors Associated with H Pylori PUD? (4)
Non Pharm Considerations?
-Avoid ___
-Dietary interventions?
-Role of probiotics?
-Keep a diary to track ?
-____ if overweight
-Elevate head of the bed how many inches?
- Environment
-Oral oral transmission
-Fecal oral transmission
-Crowded unsanitary conditions
-Developing countries
-tobacco products/smoking
-eat smaller meals, avoid trigger foods, refrain from eating within 2-3 hrs of lying down, sleep on left side, limit/discont alcohol or caffeine
-will not ultimately eradicate Hpylori
-dietary, lifestyle, and med triggers
-Weight Loss
-6-8 inches or use foam wedge
For each 1st line therapy option, state the drugs involved
- Bismuth quadruple therapy
- Concomitant (4)
- Clarithromycin triple with Amoxicillin
- Clarithromycin triple with Metronidazole
- Levoflox triple
- PPI + bismuth subsalicylate + TETRA + METRO
- PPI + Clarithro + AMOXI + METRO
- PPI + CLARITHRO + AMOXI
- PPI + CLARITHRO + METRO
- PPI + LEVOFLOX + AMOXI
For each scenario, state tx regimen
- PCN allergy NO , MACROLIDE NO
- PCN NO, MACROLIDE YES
- PCN YES, MACROLIDE NO
- PCN YES, MACROLIDE YES
- When should you use levoflox regimens?
- Bismuth quad, concomitant , clarithro triple w/amox, levoflox triple
- bismuth quad, levoflox triple, levoflox sequential
- bismuth quad, clarithro triple w/metro
- bismuth quad
- Limit use , save for salvage regimen
Kim Refer to H Pylori Dosing charts
See chart
In 1st line regimens for Hpylori PUD… What’s preferred?
Bismuth quad -Should be used preferentially because the pros»> cons. What are the pros and cons?
PPI’s over H2RA
Pros : Only option if u have macrolide exposure and or resistance is >15%
Cons : pt compliance with QID vs other regimens are BID .
-DDI risks (clopidogrel/cyp2c19 inhib with PPI’s)
-Metronidazole and alcohol
For salvage therapy, whats the additional key consideration?
in addition to PCN allergy and macrolide exposure or resistance –> avoid antibiotics that were previously taken for 1st line
When do u test for Hpylori eradication ?
at least 4 weeks after therapy completion
1-2 weeks after last PPI dose
AE’s of Bismuth Quad ?
Bismuth
PPI
Tetra
Metro
ABX in general
Bismuth – Dark stool, tongue color changes
PPI : HA, N/V/D, flatulence
Tetracycline : Photosensitivity
Metronidazole : disulfuram rxn with alcohol and taste disturbances
Abx –> Usually cause N/V. diarrhea
Salvage Therapy For H Pylori PUD Considerations :
- If pt received 1st line bismuth quad , their options are ?
-For levoflox regimens, what patient education should u tell the pt? - If pt received 1st line regimen with clarithro, options are?
- levofloxacin triple (PPI + Levoflox + Amoxi)
-Fluoroquinolones : avoid mineral fortified foods (Calcium containing OJ, cereals) –> Chelation
- Bismuth quad therapy, OR levoflox triple (ppi + amoxi + levoflox)
Which 3 drug regimens can be used for 1st line AND Salvage therapy?
Bismuth quad (PPI + bismuth + tetra + metro)
Concomitant (PPI + clarithro, amoxi + metro) )
Levoflox triple (PPI + levoflox + amoxi)
State the drug , dose, frequency, and duration for bismuth quad therapy
10-14 days
PPI once or twice daily
Bismuth 525 mg QID
Metro 250-500 mg QID
Tetracycline 500 mg QID
State the drug , dose, frequency, and duration for Concomitant therapy
10-14 days
PPI once or twice daily
Clarithromycin 500 mg BID
Metro 500 mg BID
Amoxi 1000 mg BID
State the drug , dose, frequency, and duration for Levofloxacin therapy
10-14 days
PPI Twice daily
Levoflox 500 mg daily
Amoxi 1000 mg BID
Which PPI’s are known cyp2c19 substrates and inhibitors?
Which PPI is least metabolized by CYP2C19 ?
Omeprazole , esomeprazole
Rabeprazole
State at least 3 risk factors for NSAID induced PUD?
-Age >65
-PMH PUD and or ulcer related upper GI complication
-Chronic disorders (CV Disease, RA)
-Social History : + tobacco, + etOH
What are some drug related risk factors for NSAID induced PUD?
-High dose ___
-Multiple ___
-___ inhibition
-Concomitant use of ___? (5)
-High dose NSAIDS
-MULTIPLE NSAIDS
-COX1 inhibition
-concomitant use of ASA, biphosphonates, systemic corticosteroids, clopidogrel, SSRIs
If confirmed that there’s an active ulcer through endoscopy, and the pt is H Pylori NEGATIVE what is the regimen?
May need to stop nsaid therapy.. but what about CV disease prevention?
PPI or H2RA or sucralfate x 8 weeks
Continue ASA 81 mg/day plus PPI or misoprostol
For 1st line H pylori tx suggest regimen for pts who are ..
A. PCN allergic
B. Previous exposure to macrolide
a. Bismuth quad, or clarithromycin triple with metro
b. Bismuth quad or levoflox triple
A pt has failed 1st line H pylori therapy with bismuth quad, he is NKDA, recommend salvage therapy
Pt has failed 1st line H pylori therapy with clarithro triple with amoxi, what is salvage therapy?
Levoflox triple (PPI + levoflox + Amoxi)
Bismuth quad
Patient Education for PUD H Pylori TX :
- Avoid ___ and ___
- Avoid ___
- Dietary interventions?
- AE’s of bismuth quad therapy?
- Educate on role of ___
- will need to retest again about how long after?
- PPI , H2RA OTC products
- tobacco products and smoking
- eat smaller meals, avoid triggering foods , refrain from eating within 2-3 hrs of lying down, sleep on left side , limit alcohol
- avoid excessive outside activity - wear sunscreen (tetracycline)
- probiotics
- 1 month after therapy completed
