PUD Flashcards
(28 cards)
- 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
