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3.3 MEDICATION HISTORIES OF PEPTIC ULCER DISEASE

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Table 3.3a:CASE NUMBER : 01

PATIENT DEMOGRAPHICS NAME ZAFAR ALI AGE/GENDER 60Y/M ADDRESS BUNIR

DIAGNOSIS: Duodenal ulcer, upper GI bleed (Known case of HCV)CHIEFCOMPLIANTS

PRESCRIBEDTREATMENT

STANDARDTREATMENT(Berardi RR,Welage LS. 2005)

COMPARISON

Melena, epigastric pain-1week Haemetemasis-one dayConstipation from last3days

Hospital treatmentInj octreotide 50mcg then10amp,1LD/W@15drops

per minuteInf haemaccel I/V statInj Omeprazole 40mg BDInj metoclopramide I/V statthen ODSyp Lactulose 30ml TDSDischarge medicineClarithromycin 500 mg BDCap Omeprazole 40mg BD

Amoxicillin 1g BD

Hp-eradicationOmeprazole 20 mg BDClarithromycin 500 mgtwice DailyAmoxicillin 1 g twicedailyTreatment duration is10 to 14 days

Omeprazole20mg BD should

be given

DRUG RELATED PROBLEMDose adjustment and excessive dose reference:Martin J, Cloase LA, Jordan B et al.,2009

FREQUENCY

Excessive dose Omeprazole 40mg 1Dose adjustmentin hepaticimpairment

Omeprazole 40mg Management: In cirrhotic patientOmeprazole dose should not exceed20 mg daily

Drug interactionReference:DavidS.Tatro.2004

Omeprazole-clarithromycin

1

SIGNIFICANTRATING/ONSET SEVERITY/DOCUMENTATION MANAGEMENT

3/delayed Minor/suspected Based on available data nospecial action is needed.Co-administration of thesesagents may be beneficial intreatment of h pylorieradication.

Cost related problem (Neshat MQ.2007-08) 4GENERIC BRANDS MANUFACTURER RETAIL PRICECap Omeprazole40mg

Risek (prescribed here)lozal

Omega

Getz pharma Novartis

Ferozsons

259Rs200Rs

180RsInj metoclopramide10mg

Maxolon(prescribed here)MetoclonMaxaclor

GSK Indus pharma

polyfine

118Rs80Rs50Rs

Syp Lactulose120ml

Duphalac (prescribed here)LilacWerilax

High NoonGetz pharmaWerrick

148Rs124Rs93Rs

CapClarithromycin500 mg

Klaricid (prescribed here)Claritek Clarion

AbbottGetz pharmaFerozsons

648Rs370Rs297Rs

Miscellaneous problemsReference: David S.Tatro.2004

2

counselling Not done in case of clarithromycin because it has interaction with food(significantrating2,delayed onset, moderate severity,suspected documentation)

Management: proper counselling for drugintake.Give antimicrobial before one hour of mealTake with liquids other than grape fruit juice

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Table 3.3b: CASE NUMBER :02PATIENT DEMOGRAPHICS

NAME Zubaida AGE/GENDER 40/f ADDRESS Peshawar

DIAGNOSIS: Peptic ulcer disease/depressionCHIEF COMPLIANTS PRESCRIBED

TREATMENTSTANDARDTREATMENT(Berardi RR,Welage LS. 2005)

COMPARISON

Abd.pain and epigastricdiscomfort-15days,sleepdisturbed and sunking of heart

Hospital medicationInj ranitidine 50mg I/VBD(stopped)Inj ciprofloxacin 200mg I/VBD(stopped)Tab dothiepen HCl25mg

nocte(continue)Inj metoclopramide I/V BDDischarge medicationCap amoxicillin 1g BD-14daysCap Esomeprazole 40mg OD-1monthCap clarithromycin 500mg BD

Esomeprazole 40 mgdailyClarithromycin 500mg twice DailyAmoxicillin 1 g twice

dailyTreatment duration is10 to 14 days

Pharmacotherapygiven I hospital isaccording toSTG(standardtreatmentguidelines )

DRUG RELATED PROBLEMS FREQUENCYCost related problem (Neshat MQ.2007-08) 5GENERIC BRANDS MANUFACTURER Inj ranitidine 2ml 5s Zantac(prescribed here)

Ranitidine

Ranulcid

GSK Ferozsons

Merck Marker

110Rs63Rs

64RsTab ciprofloxacin 250mg Novidate (prescribed here)

CiproquineCp zaf

SamiMacter Zafa

151Rs120Rs35Rs

Inj metoclopramide 10mg Maxolon(prescribed here)MetoclonMaxaclor

GSK Indus pharma

polyfine

118Rs80Rs50Rs

Esomeprazole 40mg Esso (prescribed here) NexumE-Mepra

ShaiganGetzAkson

159Rs323Rs130Rs

Cap Clarithromycin 500 mg Klaricid (prescribed here)Claritek

Clarion

AbbottGetz pharma

Ferozsons

648Rs370Rs

297RsMiscellaneous problemsReference: David S.Tatro.2004

1

Counselling in case of quinolone administration nocounselling has been done abt milk intake along withciprofloxacin intake because it has interaction with milk of significant rating-2(onset rapid, severity moderateand suspected documentation)

Management: avoid milk intake but if milk cannot be avoided lengthen the intake of milk anddrug as much as possible

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Table 3.3c:CASE NUMBER : 03PATIENT DEMOGRAPHICS

NAME M/O SHER AFSER

AGE/GENDER 50y/female ADDRESS Peshawar DIAGNOSIS Peptic ulcer disease(B&C negative)CHIEF COMPLIANTS PRESCRIBED TREATMENT STANDARD

TREATMENT(Berardi RR,Welage LS. 2005)

COMPARISON

Hemetemesis-1dayAbdominal pain andvomiting, black stool andloss of appetite

Hospital treatmentInf Omeprazole 40mg I/V ODInj cefotaxime 1g BD (stopped)Inf haemaccel I/V statInj octreotide 100mcg I/V stat

then 5amp in 1LD/saline@15drops per min(stopped)Inj metoclopramide I/V TDSTab clarithromycin 500mg BDTab amoxicillin 1g 1 ODDischarge medicinetab clarithromycin 500mg BD(14days)Tab amoxicillin 1g OD(14days)Tab Omeprazole 40mgOD(1month)

Hp-eradicationOmeprazole 20 mgBDClarithromycin 500mg twice Daily

Amoxicillin 1 g twicedailyTreatment duration is10 to 14 days

Pharmacotherapygiven I hospital isaccording toSTG(standardtreatmentguidelines)

DRUG RELATED PROBLEMReference: David S.Tatro.2004

FREQUENCY

Drug interaction Omeprazole-clarithromycin 1SIGNIFICANTRATING/ONSET

SEVERITY/DOCUMENTATION

MANAGEMENT

3/delayed Minor/suspected Based on available data no special action isneeded.Co-administration of theses agents may be

beneficial in treatment of h pylori eradication.Cost related problem (Neshat MQ.2007-08) 3GENERIC BRANDS MANUFACTURER RETAIL PRICECap Omeprazole 40mg Risek (prescribed here)

lozalOmega

Getz pharma NovartisFerozsons

259Rs200Rs180Rs

Inj metoclopramide10mg

Maxolon(prescribed here)MetoclonMaxaclor

GSK Indus pharma

polyfine

118Rs80Rs50Rs

Cap Clarithromycin500 mg



648Rs370Rs297Rs


2

counselling Not done in case of clarithromycin because it has interaction with food(significantrating2,delayed onset, moderate severity, suspecteddocumentation)

Management: proper counselling for drug intake.Give antimicrobial before one hour of mealTake with liquids other than grape fruit juice

Non-compliance: refused to pass I/V cannula buthowever managed.

Non-compliance during EGD proceeding

Management: pt should be clearly explained about thetherapy and the hazardous effect of not taking

prescribed drug regularly

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Table 3.3d: CASE NUMBER : 04PATIENT DEMOGRAPHICS

NAME Zar wali khan AGE/GENDER 60y/male ADDRESS Deer

DIAGNOSIS: Multiple peptic ulcers(known case of HCV)CHIEF COMPLIANTS PRESCRIBED TREATMENT STANDARD

TREATMENT

(Berardi RR,WelageLS. 2005)

COMPARISON

Melena-3daysHemetemesis-1dayAbd pain-3days

Hospital treatmentInf haemaccel 1000cc I/V STATInf Omeprazole 40mg TDSSyp Sucralfate 2TSF TDSInj metoclopramide I/V BDTab clarithromycin 500mg1BDTab amoxicillin 1g 1 BDInj vit K 10mg I/V ODDischarge medicineSyp Lactulose 2TSF (continue)Clarithromycin 500mg 1BD-14daysTab amoxicillin 1g 1 BD-14daysOmeprazole 40mg 1 OD

Hp-eradicationOmeprazole 20mg BDClarithromycin500 mg twiceDailyAmoxicillin 1 gtwice dailyTreatmentduration is 10 to14 days

Omeprazole20mg BD should

be given to patient (inhepaticimpairment doseof Omeprazoleshould notexceed 20mg)


FREQUENCY

Excessive dose Omeprazole 20mg should be given 1Dose adjustment inhepatic impairment

Omeprazole40mg In cirrhotic patientOmeprazole doseshould not exceed 20mg daily

1

Drug interactionDavid S.Tatro.2004

Omeprazole-clarithromycin 1

SIGNIFICANTRATING/ONSET

SEVERITY/DOCUMENTATION

MANAGEMENTBased on available data no special action isneeded. Co-administration of theses agentsmay be beneficial in treatment of h pylorieradication.

3/delayed Minor/suspected

Cost related problem (Neshat MQ. 2007-08)GENERIC BRANDS MANUFACTURER RETAIL PRICECap Omeprazole 40mg Risek (prescribed here)

lozalOmega


259Rs200Rs180Rs


GSK Indus pharma

polyfine

118Rs80Rs50Rs

Cap Clarithromycin 500mg



648Rs370Rs297Rs

Miscellaneous problems (Reference: David S.Tatro.2004) 1counselling Not done in case of clarithromycin because ithas interaction with food(significant rating2,delayedonset, moderate severity, suspected documentation)

proper monitoring of LFTs required in cirrhotic patientthat is not done

Management: proper counselling for drug intake.Give antimicrobial before one hour of mealTake with liquids other than grape fruit

juiceRegular check up of LFTs should bedone in order to check the progress.

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Table 3.3e:CASE NUMBER : 05PATIENT DEMOGRAPHICS

NAME Zahid khan

AGE/GENDER 40y/male ADDRESS MalakandDIAGNOSIS: PUD NSAID induced (HCV cirrhotic)CHIEFCOMPLIANTS

PRESCRIBEDTREATMENT

STANDARDTREATMENT(Berardi RR,Welage LS.2005)

COMPARISON

Abdominal pain last10daysAnorexiaVomiting(chronic user of

NSAID)

Hospital treatmentTab spironolactone 100mgOD(continue)Tab Domperidone TDS

before mealInj Ranitidine 50mg I/VBD(stopped)Syp Lactulose 30m 2TSFTDSTab frusemide 20mg 1 BDDischarge medicineTab Esomeprazole 40mg1OD(one month)Syp cyproheptadine 2TSFTDStab propranolol 10mgTDS(continue)

Esomeprazole40 mg dailyStop the NSAIDUse

in cirrhotic patient dose of Omeprazoleshould notexceed 20mgdaily


FREQUENCY

Excessive dose Esomeprazole should not exceed 20mg daily 1Dose adjustment inhepatic impairment

Esomeprazole40mg

Management: In cirrhotic patient Esomeprazole doseshould not exceed 20 mgdaily

Cost related problem ( Neshat MQ.2007-08) 2GENERIC BRANDS MANUFACTURER RETAIL PRICEInj ranitidine 2ml 5s Zantac(prescribed here)

RanitidineRanulcid

GSK FerozsonsMerck Marker

110Rs63Rs64Rs

Syp Lactulose 120ml Lilac(prescribed here)DuphalacWerilax

Getz pharmaHigh NoonWerrick

124R s148Rs93Rs

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Table 3.3 f: CASE NUMBER : 06PATIENT DEMOGRAPHICS

NAME Khawar Ali AGE/GENDER 47y/male ADDRESS Peshawar

DIAGNOSIS: PUD(NSAID induced)CHIEFCOMPLIANTS

PRESCRIBED TREATMENT STANDARDTREATMENT(Berardi RR,WelageLS. 2005)

COMPARISON

Abdominal distention&discomfort -1week Vomiting -2daysConstipation-few days(chronic use of

NSAIDs for joint pain)

Hospital treatmentInj Omeprazole 40mg 1 ODInj metoclopramide I/V STATthen ODSyp Lactulose 30ml 2TSF TDSDexamethasone topical ointmentMultivitaminsInf ciprofloxacin 100mg I/VBD(stopped)Tab Allupurinol 300mg BD(stopped)Discharge medicineTab Omeprazole 20mgBD(14days)

Omeprazole 20mg BD

Pharmacotherapygiven I hospital isaccording toSTG(standard

treatmentguidelines)

DRUG RELATED PROBLEM FREQUENCYImproper drugselection

Allupurinol was prescribed for joint pain that is notthe right choice because it is indicated for gout.Management: Nimusilde or Celecoxib is the drug

of choice for joint pain.

1

Cost related problem (Neshat MQ.2007-08) 4GENERIC BRANDS MANUFACTURER RETAIL PRICECap Omeprazole 40mg Risek (prescribed here)

lozalOmega


259Rs200Rs180Rs


GSK Indus pharma

polyfine

118Rs80Rs50Rs

Syp Lactulose 120ml Duphalac (prescribedhere)Lilac

Werilax

High NoonGetz pharmaWerrick

148Rs124R s93Rs

Tab ciprofloxacin 250mg Novidate (prescribed here)CiproquineCp zaf

SamiMacter Zafa

151Rs120Rs35Rs


1

Counselling in case of quinolone administration nocounselling has been done abt milk intake along withciprofloxacin intake because it has interaction withmilk of significant rating-2(onset rapid, severitymoderate and suspected documentation)

Management: avoid milk intake but if milk can not be avoided lengthen the intake of milk and drug as much as possible

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14 PUD CASES