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 A P Weight loss of 10 lbs. (4.5kg) in the last 6 weeks Peptic ulcer disease 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 H 2 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 protoncatalyzed 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 cysteine s 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 Inhibit acid production by reversibly competing with histamine for binding to H2 Blocker 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 positivelycharged 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 PGE 1 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 # 28 tablets Geralyn C. Salandanan, MD License no. 0000000 PTR 12345678