PUD Peptic Ulcer Disease Prince Sattam Bin AbdulAziz University College Of Pharmacy Mohammad Ruhal Ain R Ph, PGDPRA, M Pharm (Clin. Pharm) Department of Clinical Pharmacy E-mal: Pharmaco-therapeutics 2

A 42-year-old man is in the clinic with the chief concern of sharp epigastric pain for the past 6 weeks. He states that the pain is often worse with eating and that it is present at least 5 days/week. He states that although he initially tried OTC antacids with some relief, the pain returns about 3 hours after each dose. He does not currently take any other medications. He reports an allergy to penicillin, which, he states, gives him a severe rash. His practitioner is concerned about a potential peptic ulcer and tests him for H. pylori using a urea breath test, the result of which is positive. Case 1

Assessment /Classification How to classify PUD (peptic ulcer disease)? PUD Duodenal ulcer Gastric ulcer H. pylori infection (95%) NSAIDs Low-dose aspirin Epigastric pain, possibly worse at night; often, pain occurs 1–3 hours after a meal and may be relieved by eating NSAIDs, H. pylori infection Epigastric pain which is often made worse by eating; Associated symptoms may include heartburn, belching, a bloated feeling, nausea, and

Epigastric pain which is often made worse by eating is related with (Gastric ulcer / Duodenal ulcer) Epigastric pain, possibly worse at night; may be relieved by eating (Gastric ulcer / Duodenal ulcer) Choose Correct Answer

Mention complications of PUD Complications of PUD a. Bleeding b.Gastric outlet obstruction c. Perforation

A 42-year-old man is in the clinic with the chief concern of sharp epigastric pain for the past 6 weeks. He states that the pain is often worse with eating and that it is present at least 5 days/week. He states that although he initially tried OTC antacids with some relief, the pain returns about 3 hours after each dose. He does not currently take any other medications. He reports an allergy to penicillin, which, he states, gives him a severe rash. His practitioner is concerned about a potential peptic ulcer and tests him for H. pylori using a urea breath test, the result of which is positive. Case 1 Diagnosis???

Assessment/ Diagnosis I.Serologic tests Detect immunoglobulin (Ig)G to H. pylori in the serum by ELISA (enzyme-linked immunosorbent assay); 85% sensitive, 79% specific. Disadvantages Cannot distinguish between active infection and past exposure. Because antibodies persist for long periods after eradication, cannot use to test for eradication after treatment Invasive (endoscopic) Noninvasive

I. Urea breath test Detects the exhalation of radioactive CO2 after the ingestion of 13C- or 14C-radiolabeled urea. H. pylori hydrolysis of the radiolabeled urea results in CO2 production; 97% sensitive, 95% spec Advantages: Used to make a diagnosis and to test for eradication. Disadvantages Patients should discontinue antisecretory agents or antibiotics at least 2 weeks before or 4 weeks after treatment before test is performed. Noninvasive Assessment/ Diagnosis

I.Stool antigen tests detect the presence of H. pylori in the stool; 88%–92% sensitive, 87% specific Advantages: Used to make a diagnosis and to test for eradication. Disadvantages: Patients should discontinue antisecretory agents or antibiotics at least 2 weeks before or 4 weeks after treatment before test is performed Assessment/ Diagnosis Noninvasive

I. Histology: 90%–95% sensitive, 98%–99% specific, subject to sampling error I. Rapid urease tests Detect the presence of ammonia (NH3) on a sample generated by H. pylori urease activity I. Culture: Costly, time-consuming, and technically difficult, although 100% specific Assessment/ Diagnosis Invasive (endoscopic)

Which one of the following treatments for H. pylori is best for this patient ? A.Amoxicillin 1 g 2 times/day plus clarithromycin 500 mg 2 times/day plus omeprazole 20 mg 2 times/ day for 10 days. B. Cephalexin 1 g 2 times/day plus clarithromycin 500 mg 2 times/day plus omeprazole 20 mg 2 times/day for 10 days C. Bismuth subsalicylate 525 mg 4 times/day plus tetracycline 500 mg 4 times/day plus metronidazole 500 mg 3 times/day plus omeprazole 20 mg 2 times/day for 14 days. D. Levofloxacin 500 mg once daily plus metronidazole 500 mg 2 times/day plus omeprazole 20 mg 2 times/day for 5 days. Plan

Which one of the following treatments for H. pylori is best for this patient ? A.Amoxicillin 1 g 2 times/day plus clarithromycin 500 mg 2 times/day plus omeprazole 20 mg 2 times/ day for 10 days. B. Cephalexin 1 g 2 times/day plus clarithromycin 500 mg 2 times/day plus omeprazole 20 mg 2 times/day for 10 days C. Bismuth subsalicylate 525 mg 4 times/day plus tetracycline 500 mg 4 times/day plus metronidazole 500 mg 3 times/day plus omeprazole 20 mg 2 times/day for 14 days. D. Levofloxacin 500 mg once daily plus metronidazole 500 mg 2 times/day plus omeprazole 20 mg 2 times/day for 5 days. Plan

Triple-drug therapy( Clarithromycin + Amoxcillin + PPI) Quadruple-based therapy with bismuth subsalicylate metronidazole, tetracycline, and a PPI can be used for 14 days Therapy duration is 7–14 days depending on the regimen chosen. The ACG guidelines state that 14 days is preferred. Most regimens last for 10 days.

References Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton and J. Blenkinsopp © 2009 Alison Blenkinsopp Updates in Therapeutics