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Therapeutics Humber > PUD > Flashcards

PUD Flashcards

1
Q
  1. What are the 2 types of peptic ulcers?
  2. Describe the characteristics of each type
A
  1. gastric and duodenal
  2. 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

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2
Q

State the ALARM sx’s of PUD (5)

A
  1. bleeding (hematemesis, dark stools/melena, occult bleeding, anemia)
  2. unexplained weight loss
  3. dysphagia
  4. odynophagia
  5. vomiting
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3
Q

What about some most common sx’s?

Labs expected?

A

epigastric pain, abdominal pain, nocturnal pain

burning, cramping and fullness -discomfort

heartburn,belching, bloating

Low Hct, low Hgb + stool hemoccult test

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4
Q

How to differ GERD/heartburn from PUD as signs or sx’s of overlap? (5)

How to concretely differ/diagnose PUD?

A
  1. 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
  2. Endoscopy or test for H pylori
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5
Q

What are the 3 most common PUD etiologies?

A

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)

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6
Q

PUD Diagnosis using any of the following methods?

A
  1. endoscopy
  2. H.Pylori Testing (urea breath test, fecal antigen test, antibody testing, PCR)
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7
Q

Which pt’s do you test for H Pylori?

  1. All pt’s with? (4)
  2. Testing is not recc in which pt’s?
  3. Consider testing in pt’s? (3)
A
  1. -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
  2. pt’s with GERD with no PMH of PUD
  3. Long term, low dose ASA (to reduce ulcer bleed risk)

-initiating chronic NSAID therapy

    • dyspepsia but <60 yrs and no alarm features
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8
Q

For 1st line therapy for HPylori PUD what are the 2 key questions to always consider?

A

Is there a PCN allergy?

Has the pt previously taken any macrolide (azithro, clarithro, erythro) for any reason? or is the clarithromycin resistance >15%?

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9
Q
  1. 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?

A
  1. 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

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10
Q

For each 1st line therapy option, state the drugs involved

  1. Bismuth quadruple therapy
  2. Concomitant (4)
  3. Clarithromycin triple with Amoxicillin
  4. Clarithromycin triple with Metronidazole
  5. Levoflox triple
A
  1. PPI + bismuth subsalicylate + TETRA + METRO
  2. PPI + Clarithro + AMOXI + METRO
  3. PPI + CLARITHRO + AMOXI
  4. PPI + CLARITHRO + METRO
  5. PPI + LEVOFLOX + AMOXI
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11
Q

For each scenario, state tx regimen

  1. PCN allergy NO , MACROLIDE NO
  2. PCN NO, MACROLIDE YES
  3. PCN YES, MACROLIDE NO
  4. PCN YES, MACROLIDE YES
  5. When should you use levoflox regimens?
A
  1. Bismuth quad, concomitant , clarithro triple w/amox, levoflox triple
  2. bismuth quad, levoflox triple, levoflox sequential
  3. bismuth quad, clarithro triple w/metro
  4. bismuth quad
  5. Limit use , save for salvage regimen
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12
Q

Kim Refer to H Pylori Dosing charts

A

See chart

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13
Q

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?

A

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

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14
Q

For salvage therapy, whats the additional key consideration?

A

in addition to PCN allergy and macrolide exposure or resistance –> avoid antibiotics that were previously taken for 1st line

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15
Q

When do u test for Hpylori eradication ?

A

at least 4 weeks after therapy completion

1-2 weeks after last PPI dose

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16
Q

AE’s of Bismuth Quad ?

Bismuth

PPI

Tetra

Metro

ABX in general

A

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

17
Q

Salvage Therapy For H Pylori PUD Considerations :

  1. If pt received 1st line bismuth quad , their options are ?
    -For levoflox regimens, what patient education should u tell the pt?
  2. If pt received 1st line regimen with clarithro, options are?
A
  1. levofloxacin triple (PPI + Levoflox + Amoxi)

-Fluoroquinolones : avoid mineral fortified foods (Calcium containing OJ, cereals) –> Chelation

  1. Bismuth quad therapy, OR levoflox triple (ppi + amoxi + levoflox)
18
Q

Which 3 drug regimens can be used for 1st line AND Salvage therapy?

A

Bismuth quad (PPI + bismuth + tetra + metro)

Concomitant (PPI + clarithro, amoxi + metro) )

Levoflox triple (PPI + levoflox + amoxi)

19
Q

State the drug , dose, frequency, and duration for bismuth quad therapy

A

10-14 days

PPI once or twice daily

Bismuth 525 mg QID

Metro 250-500 mg QID

Tetracycline 500 mg QID

20
Q

State the drug , dose, frequency, and duration for Concomitant therapy

A

10-14 days

PPI once or twice daily
Clarithromycin 500 mg BID
Metro 500 mg BID
Amoxi 1000 mg BID

21
Q

State the drug , dose, frequency, and duration for Levofloxacin therapy

A

10-14 days
PPI Twice daily
Levoflox 500 mg daily
Amoxi 1000 mg BID

22
Q

Which PPI’s are known cyp2c19 substrates and inhibitors?

Which PPI is least metabolized by CYP2C19 ?

A

Omeprazole , esomeprazole

Rabeprazole

23
Q

State at least 3 risk factors for NSAID induced PUD?

A

-Age >65
-PMH PUD and or ulcer related upper GI complication
-Chronic disorders (CV Disease, RA)
-Social History : + tobacco, + etOH

24
Q

What are some drug related risk factors for NSAID induced PUD?

-High dose ___
-Multiple ___
-___ inhibition
-Concomitant use of ___? (5)

A

-High dose NSAIDS
-MULTIPLE NSAIDS
-COX1 inhibition
-concomitant use of ASA, biphosphonates, systemic corticosteroids, clopidogrel, SSRIs

25
Q

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?

A

PPI or H2RA or sucralfate x 8 weeks

Continue ASA 81 mg/day plus PPI or misoprostol

26
Q

For 1st line H pylori tx suggest regimen for pts who are ..

A. PCN allergic

B. Previous exposure to macrolide

A

a. Bismuth quad, or clarithromycin triple with metro

b. Bismuth quad or levoflox triple

27
Q

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?

A

Levoflox triple (PPI + levoflox + Amoxi)

Bismuth quad

28
Q

Patient Education for PUD H Pylori TX :

  1. Avoid ___ and ___
  2. Avoid ___
  3. Dietary interventions?
  4. AE’s of bismuth quad therapy?
  5. Educate on role of ___
  6. will need to retest again about how long after?
A
  1. PPI , H2RA OTC products
  2. tobacco products and smoking
  3. eat smaller meals, avoid triggering foods , refrain from eating within 2-3 hrs of lying down, sleep on left side , limit alcohol
  4. avoid excessive outside activity - wear sunscreen (tetracycline)
  5. probiotics
  6. 1 month after therapy completed

Therapeutics Humber (14 decks)

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