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

Weight loss of 10 lbs. (4.5kg) in the last 6 weeks

A
P

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
+++

Histamine H2 Receptor Antagonist

+++

+++

+++

Antacid

++

++

+++

Bismuth

+++

+++

++

Sucralfate

++

++

++

EFFICACY

SAFETY

SUITABILITY

COST

CLARITHROMYCIN

++++

+++

+++

METRONIDAZOLE

+++

++

+++

AMOXICILLIN

+++

++

+++

TETRACYCLINE

+++

++

++

++
(P 42.00/tab)
+++
(P21.00/tab)
++++
(P7.00/cap)
++++
(P6.00/tab)

PPI

ANTIBIOTICS

Cost
+++
28.75/capsule
++++
21.91/tablet
++++
7/tablet
++
31.85/tablet
+
42.62/tablet

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

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 H2 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 cysteines 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
Blocker

Inhibit acid production by reversibly competing with histamine for binding to H 2

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
Inhibits protein synthesis in susceptible organisms by penetrating the cell wall and
binding to 50S ribosomal subunits
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 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.

Clarithromycin
Amoxicillin
Metronidazole

Misoprostol

Is a PGE1 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