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therapeutics > Ex.6 PUD (64) > Flashcards

Ex.6 PUD (64) Flashcards

1
Q

Peptic Ulcer Disease

A

Large Ulcers (greater than or equal to 5 mm) and extend deeper into the muscularis mucosa
-Types of ulcers: gastric, duodenal

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2
Q

Epidemiology

A

-Lifetime prevalence is between 5-10% in the US
-H. Pylori prevalence is 30-40%
-PUD is prevalent among 30-50% of chronic NSAID users

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3
Q

Contributing Factors

A

H. Pylori infection
NSAID use
Gastric acid + Pepsin
Cigarette smoking
Critical illness
Dietary Factors

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4
Q

Pathophysiology

A

Aggressive factors (gastric acid and pepsin) overcome protective factors (mucosal defense and repair)

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5
Q

Life threatening Complications:

A

GI Bleed
GI Perforation
GI obstruction

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6
Q

Signs and symptoms

A

Epigastric pain
Nausea
Belching, heartburn
Bloating, Abdominal fullness
Weight loss
Early satiety

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7
Q

Goals of Care

A

Relieve ulcer symptoms
Heal the ulcer
Prevent recurrence and complications
Eradicate or withdrawal of offending agent

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8
Q

Non-Pharmacologic Therapy

A

Stress reduction
Smoking cessation
Avoid food and drink triggers
Avoid NSAIDs
Surgery

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9
Q

H. Pylori induced Pathophysiology + Diagnosis

A

Pathophysiology
-Bacteria bind to the epithelial wall and colonize gastric acid
-Gastric acid damages tissue and leads to ulcer

Diagnosis:
-endoscopy
-Antibody detect
-Urea breath test
-Fecal antigen

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10
Q

Principles of H. Pylori Tx

A

Several different tx. regimen options

Typically consists of acid suppressor + 2-3 antibiotics

Helpful to determine if patient has had any recent antibiotic exposure to predict resistance

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11
Q

Therapy Overview

A

Bismuth
-Quad therapy

Clarithromycin:
-Triple therapy
-Concomitant therapy
-Sequential therapy
-Hybrid therapy

Levofloxacin
-Triple therapy
-Quad therapy (LOAD)
-Sequential therapy

Rifabutin
-Triple therapy

Vonoprazan
-Dual therapy
-Triple therapy

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12
Q

Bismuth - Quad therapy

A

Bismuth salts
-Topical bactericidal effect by inhibiting aggressive factors and increasing protective factors

AVOID salicyclate products in children <12 years old due to risk of Reye’s syndrome

Contains:
1. PPI BID
2. Bismuth subsalicyclate 525mg QID
3. Metronidazole 250-500mg QID
4. Tetracycline 500mg QID
10-14 days
PREFERRED REGIMEN

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13
Q

Convenience packaging for H. Pylori - Helidac

A

Helidac
-Daily admin package
-“Bismuth quadruple”
-14 blister cards containing:

-Metronidazole 250mg (i tab QID)
-Tetracycline 500mg (1 tab QID)
-Bismuth subsalicyclate 262.4mg (2 tabs QID)
-Must also take PPI BID

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14
Q

Convenience packaging for H Pylori - Pylera

A

3-in-1 capsule containing:
-Bismuth subcitrate potassium 140mg
-Metronidazole 125mg
-Tetracycline 125 mg

Dose: 3 caps QID for 10 days
Must also take PPI BID
Bismuth quadruple

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15
Q

Therapy overview: Clarithromycin Triple therapy and concomitant therapy

A

Triple:
1. PPI BID
2. Clarithromycin 500mg BID
3. Amoxicillin 1G BID OR Metronidazole 500mg BID
*14 days
Note: Triple therapy is no longer recommended in the US due to macrolide resistance

Concomitant:
1. PPI BId
2. Clarithromycin 250-500mg BID
3. Amoxicillin 1G BID
4. Metronidazole 250-500mg BID
*10-14 days

Note: Concomitant or “Non-Bismuth Quad” is also another first line therapy

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16
Q

Clarithromycin Sequential and hybrid Therapy

A

Sequential:
1. PPI BID (days 1-10)
2. Amoxicillin 1G BID (days 1-5)
3. Metronidazole 250-500mg BID (days 6-10)
4. Clarithromycin 250-500mg BID (days 6-10)
*10 days

Hybrid:
1. PPI BID (days 1-14)
2. Amoxicillin 1G BID (days 1-14)
3. Metronidazole 250-500mg BID (days 7-14)
4. Clarithromycin 350-500mg BID (days 7-14)
*14 days

17
Q

Levofloxacin therapies

A

Triple Therapy
1. PPI BID
2. Levo 500mg daily
3. Amoxil 1G BID
*10-14 days

Quad therapy (LOAD)
1.Levo 250mg daily
2. Omeprazole (or other PPI) at high dose once daily
3. Nitazoxandine 500mg BID
4. Doxycycline 100mg Daily
*7-10 days

Sequential
1. PPI BID (days 1-10)
2. Amoxil 1G BID (days 1-5)
3. Levo 500mg daily (days 6-10)
4. Metro 500mg BID (days 6-10)
*10 days

18
Q

Rfabutin - Triple Therapy

A
  1. Omeprazole 40mg Q8H
  2. Amoxil 1G Q8h
  3. Rifabutin 50mg 18H
    *14 days

No determined place in therapy, typically used as a salvage therapy currently

19
Q

Vonoprazan therapy

A

Potassium-Competitive Acid Blocker
-Inhibits H/K ATPase in parietal cells via competitive antagonist of potassium
Onset
2-3 hours
Indications
PUD and Erosive GERD

20
Q

Vonoprazan Dual and triple therapy

A

Dual:
1. Vono 20mg BID
2. Amoxil 1G Q8H
*14 days

Triple:
1. Vono 20mg BID
2. Amoxil 1G BID
3. Clarithromycin 500mg BID
*14 days

21
Q

Importance of PPIs in H. Pylori

A

BID PPIs are the backbone of tx

Antisecretory effects from PPIs enhance antibiotic activity
-PPIs have been shown to produce higher eradication rates

-H2RAs should not be used unless patient cannot tolerate PPI

PPIs usually not necessary beyond 2 weeks of use for eradication

Decrease in acidity, increase in antibiotic concentration

22
Q

PPI dosing H pylori

A

Omeprazole(Prilosec):
20mg

Pantoprazole (Protonix):
40mg

Esomeprazole (Nexium):
20-40mg

Lansoprazole (Prevacid)
30mg

23
Q

Probiotics

A

Could potentially be used as prophylaxis for H. Pylori colonization

Can be taken to supplement antibiotic therapy to increase eradication rates when compared to placebo
-May also reduce adverse effects of therapy

24
Q

Adverse effects probiotics

A

Metronidazole
-Avoid alcohol due to disulfiram-like rxn

Clarithromycin
-GI upset (N/V/D)

Tetracycline
-Photosensitivity
-Avoid use in children

Bismuth Salts
-Darkening of stool and tongue

25
Q

Treatment considerations: Probiotics

A

Avoid antibiotics the patient has already taken
Patient adherence
Consider allergies + intolerances

26
Q

Factors that predict treatment outcomes

A

Antibiotic resistance
Poor medication adherence
Short duration of therapy
High bacterial load

27
Q

Treatment Failure

A

Confirmed by diagnostic test 4 weeks after completion of antibiotics and after PPI has been d/c for 2 weeks

Patients who failed tx should:
-Be referred to gastroenterologist
-Perform a penicillin skin test if allergy previously listed

28
Q

Treatment failure: selecting salvage therapy

A

Chose antibiotics that were not used in previous regimen

Reference local or institution specific resistance rates

Use an extended tx. duration of 10-14 days

29
Q

NSAID Induced PUD pathophysiology

A

Rule out H. Pylori and confirm with
-Endoscopy
-Low Hgb and Hct if ulcers are bleeding

30
Q

Patients at diff levels of risk for NSAID GI toxicity

A

High Risk
-History of a previously complicated ulcer, especially recent
-Multiple (>2) risk factors

Moderate risk (1-2 factors)
-Age >65 years
-High dose NSAID therapy
-A previous hx of uncomplicated ulcer
-Concurrent use of aspirin (including low dose) corticosteroids or anticoagulants

Low risk
-No risk factors

31
Q

Prevention of NSAID induced PUD

A

PPI
H2RA
Misoprostol
COX-2 Inhibitor (admin with NSAID)

32
Q

Misoprostol (Cytotec)

A

Dosing:
200mcg QID with food

MOA:
-Prostaglandin E1 analog
-Increased mucus and bicarbonate secretion
-Increased surface active phospholipids
-Increased gastric mucosal blood flow inhibits acid secretion

SE: N/V/D, abdominal cramping, flatulence, HA

BOXED WARNING
-Pregnancy category X: induces labor or abortion
-MUST CONFIRM patient is not pregnant in women of child-bearing age

33
Q

Celecoxib (Celebrex)

A

MOA: selective inhibition of COX-2

Equivalent anti-inflammatory effects but preserves prostaglandins

BOXED WARNING
Increased risk of CV events

Naproxen is the preferred non-selective agent due to decreased CV risk

34
Q

Treatment: Sucralfate (Carafate)

A

Dosing:
1g QID before meals and at bedtime

MOA: sucrose-sulfate-aluminum complex that interacts with albumin and fibrinogen to form a physical barrier over an open ulcer -> protects ulcer to allow it to heal

SE:
Constipation, metallic taste, aluminum toxicity in chronic renal failure

Counseling:
-Admin on empty stomach 2 hours before or 4 hours after other medications

34
Q

Tx of NSAID induced PUD

A

If patient can stop NSAID:
-PPI, H2RA or sucralfate for 8 weeks

If patient is continuing NSAID:
-PPI for 12 weeks
-Use lowest effective dose NSAID
-May consider continuing PPI

therapeutics (49 decks)

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