Pharmacotherapy of Peptic Ulcer Disease
PST 06106
Basic Pharmacotherapy
Session 23: Pharmacotherapy of Peptic Ulcers Disease
Learning Objective
By the end of this session students are expected to be able to:
Define peptic ulcers disease
Explain pathophysiology of peptic ulcers disease
Explain the clinical presentation of peptic ulcers disease
Outline diagnosis of peptic ulcers disease
Describe pharmacological treatment of peptic ulcers disease
Describe the monitoring of peptic ulcers disease
therapy
Activity: Buzzing
What is Peptic ulcer Disease?
Definition of Peptic Ulcers Disease
Peptic
ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum.
Peptic ulcer disease (PUD), also known as a peptic ulcer or stomach ulcer, is a break in the lining of the stomach, first part of the small intestine, or occasionally the lower
oesophagus
An ulcer in the stomach is known as a
gastric ulcer
while that in the first part of the intestines is known as a
duodenal ulcer
.
Most ulcers are caused by an infection with a type of bacteria called
Helicobacter pylori
(H. pylori).
Definition of Peptic Ulcers
Disease Cont..
Factors that can increase your risk for ulcers include:
Use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as;
Aspirin, even safety-coated aspirin and aspirin in powered form can frequently cause ulcers.
naproxen,
ibuprofen
Definition of Peptic Ulcers Disease Cont..
Many other prescription drugs such;
Concomitant use of oral bisphosphonates (e.g., alendronate)
Concomitant use of corticosteroids
Concomitant use of anticoagulant or coagulopathy
Concomitant use of antiplatelet drugs (e.g.,
clopidogrel
)
Concomitant use of selective serotonin reuptake inhibitor
Definition of Peptic Ulcers Disease Cont..
Excess
acid production from
Zollinger
-Ellison syndrome, (ZES)
gastrinomas
,
tumors
of the acid producing cells of the stomach that increases acid output
Excessive drinking of alcohol
Smoking or chewing tobacco
Peptic ulcers are also associated with radiation, chemotherapy, vascular insufficiency, and other chronic
diseases
Pathophysiology of Peptic Ulcers Disease
A physiologic imbalance between aggressive (gastric acid and pepsin) and protective factors (mucosal defense and repair) remain important issues in the pathophysiology of gastric and
duodenal ulcers.
Gastric acid is secreted by the parietal cells, which contain receptors for histamine, gastrin, and acetylcholine.
Acid (as well as
H. pylori
infection and NSAID use) is an independent factor that contributes to the disruption of mucosal integrity.
Increased acid secretion has been observed for patients with duodenal with Zollinger-Ellison syndrome (ZES) (described in the
section
Pathophysiology of Peptic Ulcers
Disease Cont..
Zollinger-Ellison Syndrome) have profound gastric acid hypersecretion resulting from a gastrin-producing tumor
H. pylori
produce large amounts of urease, which hydrolyzes urea in the gastric juice and converts it to ammonia and carbon dioxide.
The local buffering effect of ammonia creates a neutral microenvironment within and surrounding the bacterium, which protects it from the lethal effect of gastric acid
.
H. pylori
also produces acid inhibitory proteins, which allows it to adapt to the low-pH environment of the stomach
Pathophysiology of Peptic Ulcers Disease Cont..
Mucosal
injury is produced by
elaborating bacterial enzymes (urease, lipases, and proteases),
Lipases and proteases degrade gastric mucus, ammonia produced by urease may be toxic to gastric epithelial cells,
Adherence
bacterial adherence enhances the uptake of toxins into gastric epithelial cells
H. pylori virulence factors.
H. pylori
induces gastric inflammation by altering the host inflammatory response and damaging epithelial cells directly by cell-mediated immune mechanisms or indirectly by activated neutrophils or macrophages attempting to phagocytose bacteria or bacterial products
Clinical presentation and Diagnosis of Peptic ulcers disease
The clinical presentation of PUD varies depending on the severity of epigastric pain and the presence of complications
Ulcer-related pain in duodenal ulcer often occurs 1 to 3 hours after meals and is usually relieved by food, but this is
variable
General
Mild epigastric pain or acute life-threatening upper gastrointestinal
complications
Clinical presentation and Diagnosis of Peptic ulcers
disease
Cont
….
Symptoms
Abdominal
pain that is often epigastric and described as burning but may present as vague discomfort, abdominal fullness, or cramping
A typical nocturnal pain that awakens the patient from sleep (especially between 12 AM and 3 AM)
The severity of ulcer pain varies from patient to patient and may be seasonal,
episodes of discomfort usually occur in clusters, lasting up to a few weeks and followed by a pain-free period or remission lasting from weeks to years
Clinical presentation and Diagnosis of Peptic ulcers disease
Cont
….
Symptoms…..
Changes
in the character of the pain may suggest the presence of complications
Heartburn, belching, and bloating often accompany the pain
Nausea, vomiting, and anorexia are more common for patients with gastric ulcer than with duodenal ulcer but may also be signs of an ulcer-related complication
Clinical presentation and Diagnosis of Peptic ulcers disease
Cont
….
Signs
Weight loss associated with nausea, vomiting, and anorexia
Complications including ulcer bleeding, perforation, penetration, or
obstruction
Laboratory tests
Gastric acid secretory studies
The
hematocrit
and
hemoglobin
are low with bleeding, and stool
hemoccult
tests are positive.
Tests for
Helicobacter pylori
.
Clinical presentation and Diagnosis of Peptic ulcers disease
Cont
….
Diagnostic tests
Fiberoptic
upper endoscopy (esophagogastroduodenoscopy) detects more than 90% of peptic ulcers and permits direct inspection, biopsy, visualization of superficial erosions, and sites of active bleeding.
Upper gastrointestinal radiography with barium and upper endoscopy are also the diagnostic procedures for suspected peptic ulcer.
Tests for Detection of Helicobacter
Pyroli
Activity
: Small Group Discussion
What is the treatment of Peptic Ulcers Disease
?
Pharmacological Treatment of Peptic Disease
The treatment of chronic PUD varies depending on the etiology of the ulcer (
H. pylori
or NSAID), whether the ulcer is initial or recurrent, and whether complications have occurred
Overall treatment is aimed at relieving ulcer pain, healing the ulcer, preventing ulcer recurrence, and reducing ulcer-related complications.
The goal of therapy for
H. pylori
positive patients with an active ulcer, a previously documented ulcer, or a history of an ulcer-related complication, is to eradicate
H. pylori,
heal the ulcer, and cure the disease.
Successful eradication heals ulcers and reduces the risk of recurrence for most patients
.
Drug Regimens Used to Eradicate Helicobacter pylori
Pharmacological Treatment of Peptic
Disease Cont..
Other options for Triple therapy for eradication of the H. pylori include;
Omeprazole (PO) 20mg twice daily Plus
Amoxycillin
(PO) 1000mg twice daily
AND
Metronidazole
(PO) 400mg twice daily for 10–14 days
OR
Lansoprazole (PO) 30mg twice daily
AND
Clarithromycin
(PO) 500mg twice
AND
Tinidazole (PO) 500mg twice daily for 10–14 days
OR
Any combination of PPI + 2 antibiotics active for
H. pylori
Other
drugs as indicated in the table below can also be used in the treatment of peptic ulcer
disease
Oral Drug Regimen Used To Heal Peptic Ulcer And Maintain Ulcer Healing
Monitoring of Peptic Ulcers Disease Therapy
Treatment of
Helicobacter pylori
-associated ulcer
Assess patient allergies to determine if allergic to penicillin (or other antibiotics) so that drug regimens that contain penicillin (or other antibiotics) can be avoided.
Assess patient use of alcohol or alcohol-containing products with metronidazole and oral birth control medications with antibiotics and counsel appropriately.
Assess likelihood of nonadherence to the drug regimen as a cause of treatment failure.
Recommend a different antibiotic combination if
H . pylori
eradication fails
.
Monitoring of Peptic Ulcers Disease
Therapy Cont.…
Inform the patient of change in stool color when bismuth salicylate is included in an
H. pylori
eradication regimen.
Assess and monitor patients for potential adverse effects, especially those associated with metronidazole, clarithromycin, and amoxicillin.
Assess and monitor patients for potential drug interactions, especially those receiving metronidazole, clarithromycin, or cimetidine.
Monitor patients for persistent or recurrent symptoms within 14 days after completion of a course of
H. pylori
eradication therapy.
Monitoring of Peptic Ulcers Disease
Therapy Cont.….
Provide
patient education to patients who are receiving
H . pylori
eradication therapy and include why antibiotic and antiulcer combinations are used;
when and how to take medications;
adverse effects;
alarm symptoms;
the importance of adherence to the entire course of drug treatment; and
Contact their healthcare provider if alarm symptoms develop (e.g., blood in the stools, black tarry stools, vomiting, severe abdominal pain), or if symptoms persist or return after H. pylori eradication
.
Monitoring of Peptic Ulcers Disease Therapy
Treatment of NSAIDS induced ulcers
Monitor
patients for signs and symptoms of NSAID-related upper GI complications.
Assess and monitor patients for potential drug interactions and adverse effects (especially misoprostol).
Provide patient education to patients who are at risk of NSAID-induced ulcers or GI-related complications and include why
co-therapy
is used with nonselective NSAIDs;
when and how to take medications;
adverse effects;
alarm symptoms;
when to contact their healthcare provider; and
The importance of adherence to drug treatment
.
Key
Points
Peptic
ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum
A physiologic imbalance between aggressive (gastric acid and pepsin) and protective factors (mucosal defense and repair) and
H. pylori
infection remain important issues in the pathophysiology of gastric and duodenal ulcers.
Symptoms of PUD include abdominal pain that is often epigastric and described as burning but may present as vague discomfort, abdominal fullness, or cramping
The treatment of chronic PUD varies depending on the etiology of the ulcer (
H. pylori
or NSAID), whether the ulcer is initial or recurrent, and whether complications have occurred
Evaluation
What
is Peptic Ulcers Disease?
What is the pathophysiology of
Peptic Ulcers Disease
?
What are the signs and symptoms of Peptic Ulcers Disease?
How is the treatment of Peptic Ulcers Disease?
References
Wells
BG,
DiPiro
J,
Schwinghammer
T (2013),
Pharmacotherapy Handbook
(6
th
Ed). New York, NY: McGraw-Hill.
DiPiro
JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey ML, (2008):
Pharmacotherapy: A Pathophysiologic Approach
(7
th
ed
): New York, NY: McGraw-Hill.
Katz M D.,
Matthias KR.,
Chisholm-Burns M A.,
Pharmacotherapy(2011)
Principles & Practice Study Guide: A Case-Based Care Plan Approach
:
New York, NY: McGraw-Hill.
Schwinghammer
TL, Koehler JM (2009)
Pharmacotherapy Casebook: A Patient-Focused Approach
(7
th
ed
): New York, NY: McGraw-Hill.
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