Case 4: Peptic Ulcer Disease

Requejo, April Salandanan, Geralyn Talingting, Vennessa

Tanay, Arvie

Case 4: PUD Problem List:

1. Peptic Ulcer Disease SOAP Note: S Patient is complaining of abdominal pain and heartburn that occurs 2-3 times a week.

O Weight loss of 10 lbs. (4.5kg) in the last 6 weeks

A Peptic ulcer disease P 3 /4 Drug Regimen for H. pylori related PUD

Goal: Treat and prevent recurrence of Peptic Ulcer Disease Objectives:

1. Determine the possible underlying mechanism or etiology of PUD and differentiate the ulcer induced by H. pylori, NSAID, and Stress related mucosal damage (SRMD) in terms of pathogenesis, risk factor, signs and symptoms, clinical cause and prognosis

2. Eradicate H. pylori infection 3. Treat NSAID related ulcer 4. Identify the factors that guide the treatment for H. pylori infection 5. Devise treatment algorithm for evaluation of treatment of patient with H. pylori

infection and NSAID induced ulcer Intervention Pharmacologic:

1. Differentiate ulcer induced by H. pyori, NSAID, and SRMD

2. Choose which drug regimen will you use

Drug Efficacy Safety Suitability Cost

PPI ++++ ++++ +++ +++ 28.75/capsule

Histamine H2 Receptor Antagonist +++ +++ +++ ++++ 21.91/tablet

Antacid ++ ++ +++ ++++ 7/tablet

Bismuth +++ +++ ++ ++ 31.85/tablet

Sucralfate ++ ++ ++ + 42.62/tablet

ANTIBIOTICS EFFICACY SAFETY SUITABILITY COST

CLARITHROMYCIN ++++ +++ +++ ++ (P 42.00/tab)

METRONIDAZOLE +++ ++ +++ +++ (P21.00/tab)

AMOXICILLIN +++ ++ +++ ++++ (P7.00/cap)

TETRACYCLINE +++ ++ ++ ++++ (P6.00/tab)

3. For patients who must continue NSAID use or if with severe inflammatory conditions:

o Lowest possible dose and duration of NSAID is considered o PPI maintenance is recommended to prevent recurrence o Changing to COX-2 selective inhibitor might be an option

o Co-therapy with PPI or misoprostol (at low doses) for active ulcers

4. Identify the factors that guide the treatment for H. pylori infection. a. Single-antibiotic regimens are ineffective in eradicating H. pylori infection and lead

to microbial resistance. b. Proton pump inhibitor or H2 receptor antagonist significantly enhances the

effectiveness of H. pylori antibiotic regimens containing amoxicillin or clarithromycin.

c. Regimen of 10-14 days of treatment appears to be better than shorter treatment regimens

d. Poor patient compliance is linked to the medication-related side effects experienced by as many as half of patients taking triple-agent regimens, and to the inconvenience of three- or four-drug regimens administered several times per day. Packaging that combines the daily doses into one convenient unit is available and may improve patient compliance.

e. Finally, the emergence of resistance to clarithromycin and metronidazole increasingly is recognized as an important factor in the failure to eradicate H. pylori.

5. Devise treatment algorithm for evaluation of treatment of patient with H. pylori infection and NSAID induced ulcer

Non pharmacologic Treatment

1. Lifestyle Modification a. Stop smoking b. Avoid alcohol intake

Notes: Drugs mechanism of action

PPI Blocks the final step in acid production. After absorption into the systemic circulation, the prodrug diffuses into the parietal cells of the stomach and accumulates in the acidic secretory canaliculi, where it is activated by proton-catalyzed formation of a tetracyclic. There is trapping the drug so that it cannot diffuse back across the canalicular membrane making it irreversible. The activated form then binds covalently with sulfhydryl groups of cysteines in the H+, K+-ATPase, inactivating the pump molecule. Acid secretion resumes only after new pump molecules are synthesized and inserted into the luminal membrane, providing a prolonged suppression of acid secretion

H2 Receptor Blocker

Inhibit acid production by reversibly competing with histamine for binding to H2 receptors on the basolateral membrane of parietal cells

Bismuth Forms complex with mucus to coat ulcer crater Has an antimicrobial property against H. pylori

Sucralfate Protects GI lining against peptic acid, pepsin and bile salts by binding with positively-charged proteins in exudates forming a viscous paste-like adhesive substance thus forming a protective coating

Clarithromycin Inhibits protein synthesis in susceptible organisms by penetrating the cell wall and binding to 50S ribosomal subunits

Amoxicillin Inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall by binding to 1 or more of the penicillin-binding proteins (PBPs), thus inhibiting cell wall biosynthesis resulting in bacterial lysis.

Metronidazole Metronidazole is converted to reduction products that interact w/ DNA to cause destruction of helical DNA structure and strand leading to a protein synthesis inhibition and cell death in susceptible organisms. It is active against most anaerobic protozoa and facultative anaerobes.

Misoprostol Is a PGE1 analog which can prevent gastric injury by cytoprotective effects that include stimulation of mucin and bicarbonate secretion and increased mucosal blood flow. Although smaller doses than those required for acid suppression can protect the gastric mucosa.

Dosage and Frequency:

Sample Prescription

Geralyn C. Salandanan, M.D. FEU-NRMF Medical Center

Monday-Friday (8:00am -12:00 noon) Tel # 888-8888

Rx Clarithromycin 500mg/tablet

(Biaxin) Sig: Take 1 tablet twice a day for 14 days

Geralyn C. Salandanan, MD License no. 0000000

PTR 12345678

# 28 tablets