Clinical Pharmacology

July 2, Process of Rational Prescribing

2015 Maria Luisa D. Dela Cruz, MD

Case
45 year old male
severeepigastric pain
Stool exam: (+) occult blood
Hgb: 10 g% (N 120-160)
Stool examination: + occult blood
Gastroendoscopy: Duodenal ulcer + H pylori

We have to look at the patient as a person, holistically, not

just the disease itself.

1. Define the Patients Problem

In the parietal cell, there are 4 types of receptors:
Problem list: histaminergic, prostaglandin, acetylcholine, and gastrin. All
o Severe epigastric pain the receptors except prostaglandin stimulates the secretion of
o Melena acid. The final pathway for the secretion of gastric acid is the
o Mild anemia release of H in the gastric lumen to combine with Cl to form
o 2.5 cm ulcer duodenal bulb HCl. The mechanism H is expelled in the lumen is by a proton
There are some cases when you need to individually pump, the H-K-ATPase.
tackle a problem, but sometimes you can come up with a
specific diagnosis with whats available, then we This is why proton pump inhibitors (PPIs) are more potent than
approach the problem based on the diagnosis. H2 blockers, because histamine-2 blockers only inhibit
histaminergic receptors in the parietal cells, but cholinergic
and gastrin receptors remain. PPIs, on the other hand, inhibit
Patient usually presents with a problem
the final pathway for acid production. Prostaglandin acts
Thorough history and P.E. to identify patients real
through mucus production and motility.
problem
How patient perceives problem
Peptic ulcer disease
H. pylori associated Duodenal Ulcer
o Theres no need to tackle the problems one
at a time, you can address the entire
problem if you know the diagnosis

The continuous presence of the hostile factors will cause a

decrease in the barrier function of the stomach and Pepsin can
digest the gastric mucosa leading to erosion that can create an
ulcer.

In the stomach, there should be a balance between the hostile

and protective factors. Ulcer results from the predominance
of the hostile factors.

Just a brief review of the protective factors:

Bicarbonate neutralizes the acid
Prostaglandin maintenance of gastric mucosal barrier
Mucus production protection of gastric epithelium
Mucosal blood flow sustains viability of mucous cells
Ulcers can be detected through barium studies or through
gastroendoscopy. The duodenal bulb is a common location for
duodenal ulcers.

Transcribed By: Aaron Lalusin

Edited by: Lloyd Lim Formatted By: Aya Chang Page 1 of 4
H. pylori and Peptic Ulcer Disease
90% of duodenal ulcer, 70% of gastric ulcers
For effective treatment and prevention of
complications and recurrence
Acid suppression + H. pylori eradication
H. pylori colonizes the mucosa and creates an
inflammatory reaction. This breaks the barrier
function of the stomach and allows acid to penetrate
and cause an ulcer. Treatment should be not only to
suppress gastric acid, but also to destroy H. pylori.
2. Therapeutic Objectives
To relieve symptoms
o Sometimes you have to treat the symptoms
before you can treat the disease
To treat the disease
To prevent complications or recurrences
To prevent disease
o Even before a disease is established, the goal
of treatment should be prevention. This is
our ultimate objective.
Good way to plan out management options
Prevent unnecessary drug use
Prevent unnecessary prophylactic drug use
Complications of PUD: perforation, extension to other organs
like the pancreas (this is dangerous because of the lytic
enzymes in the pancreas), hemorrhage, and obstruction (when
the ulcer heals it can cause fibrosis and stenosis causing
obstruction)
3. Verify Suitability of Treatment
Non-drug measures
There should always be non-drug measures because
they are an important adjunct to treatment
Personal hygiene
o Transmission of H. pylori infection is still
unknown
o Many diseases can be prevented just by
thorough hand washing
Regular meals
Avoid caffeinated drinks
Edited by: Lloyd Lim
o There havent been studies that suggest
drinking coffee predisposes you to ulcer
formation, but you have to limit it when you
already have an ulcer
Stop smoking
o Destroys barrier function of the stomach
o Inhibits production of bicarbonate and alters
mucosal blood flow
Alcohol in moderation
o Alcohol distends the stomach and triggers
the secretion of gastrin, which causes acid
secretion
Drug measures
Three Basic Categories of Action
1. Treat without drugs
2. Treat with drug/drugs
3. Refer to specialist for treatment
Criteria for Choosing Drug
1. Safety
2. Efficacy
3. Convenience
4. Cost
You may have to give a score for each criterion. The drug with
the highest total will be the best choice.
EFFICACY
Check on the Following:
1. Are the drug/s and dosage form suitable for the
patient?
2. Is the standard dosage schedule suitable?
3. Is the standard duration of treatment suitable?
3.A. Active Drug and Dosage Form
Best recommended drug for the condition
o This is evidence based
o In our manuals, there is a list of core drugs
and complimentary drugs.
Dosage form is convenient for the patient
o Very young patients cant take big capsules
and the elderly may have difficulties with
solids
o Improves compliance to treatment
o Major obstacles include complicated dosage
forms or packages and special storage
requirements
E.g., you cant ask a patient to inject
himself with a drug intramuscularly
Some drugs need to be refrigerated
3.B. Standard Dosage Schedule
Aim is to maintain plasma levels within the
therapeutic window
The dosage schedule should be effective and safe
Two main reasons why a standard dosage schedule may
have to be adapted:
a. Window and/or plasma curve may have changed, OR
b. Dosage schedule is inconvenient to the patient
Transcribed By: Aaron Lalusin Page 2 of 4
Formatted By: Aya Chang
 Check for factors that may decrease efficacy or First-Line Regimens for Helicobacter pylori Eradication
increase toxicity (pharmacodynamics) Eradication
o E.g., age, pregnancy, hepatic or renal disease Regimen Duration
Rates
Comments
Check for factors that may interfere with absorption, Bismuth subsalicylate 525 1014 7590% Consider in
distribution, metabolism, and excretion mg QID + Metronidazole penicillin allergic
(pharmacokinetics) 250 mg QID + Tetracycline patients
Should be convenient to the patient for better 500 mg QID +
adherence (compliance) Ranitidine 150 mg BID or
o Drugs that are more frequently administered standard dose PPI OD or
have lower adherence BID
Adapt dosage schedule to the convenience of the PPI + Amoxicillin 1 g BID 5 >90% Requires validation
patient followed by: in North America
How to adapt a dosage schedule PPI + Clarithromycin 500 5
1. Adjust dose mg + Tinidazole 500 mg
2. Adjust frequency of administration BID
3. Both

SAFETY
Decreasing the daily dose is usually easy, but beware of
Check on the Following:
antibiotics as some may need high peaks in plasma
1. Contraindications (high risk groups, other diseases)
concentration to be effective. On the other hand, increasing
2. Interactions (drug, food, alcohol, smoking)
(e.g. doubling the dose) the daily dose while maintaining the
3. Adverse reactions
same frequency is a little more complicated as it also increases
the fluctuations on both sides of the curve, especially in drugs
with narrow safety margins. The safest way to prevent this is 4. Write A Prescription
to raise the frequency.
Review Parts of the Prescription
3.C. Standard Duration of Treatment Efficacy Date
Adequate dose and duration of treatment o Indicates when the patient was seen
o Antibiotic treatment needs to be completed o Helps in monitoring
for 7-14 days while fungal treatment needs 4 Name, address, and age of the patient
weeks Drug prescribed
o There are certain conditions wherein the o Consists of the generic name of the drug, the
duration of treatment is definite available/chosen dosage form, and the
No over- or underprescribing available preparation
Direction to the pharmacist or dispenser
Regimens for H. Pylori Associated Duodenal Ulcer o Usually contains the amount to be given to
the patient
Directions to the patient
o Should be clear to the patient
o If the patient cant understand English, state
it in the vernacular
Prescribers identity
o Name of the doctor, license number, others
(PTR no., S2 no., etc.)
Signature of the physician
o A prescription is a legal document
o This signifies that you have full responsibility
for the prescription

Treatment is more complicated because you have to inhibit

acid secretion and eradicate the organism. Ordinary PUD is
given PPI once a day, but PPI is given twice a day if its H. pylori
associated.

This is given before meals because acid can inactivate it.

Transcribed By: Aaron Lalusin Page 3 of 4

Edited by: Lloyd Lim Formatted By: Aya Chang
 Aids to Improving Patient Adherence to Treatment

Patient leaflets
Pictures
Drug calendar
Drug leaflet
Dosage box

6. Monitoring Treatment

Monitor treatment outcome by:

Passive monitoring
o Patient monitors his/her treatment
Active monitoring
o Physician does the monitoring

Summary for Treatment Monitoring:

Was the treatment effective?

Yes, and disease cured: Stop the treatment

Yes, but not yet Any serious side effects?

completed: -No: treatment can be
continued
-Yes: reconsider dosage or
drug choice

No, disease not cured Verify all steps

- Diagnosis correct?
-Therapeutic objective correct?
- P-drug suitable for this
5. Give Information, Instruction, Warnings patient?
- Drug prescribed correctly?
Therapeutic effects of the drug - Patient instructed correctly?
o Explain the effects of the drug and why - Effect monitored correctly?
youre giving it
Adverse effects
o There are hypochondriacs that would be
-END-
affected if you just enumerated all of the
possible adverse effects Red boxes editors notes
o In case there is anything you feel after you Green boxes excerpts lifted from our Clinical
start taking the drug, report to me Pharmacology Lab Manual, as Dra. Dela Cruz also
immediately. Dont disregard it because it instructed us for additional readings regarding rational
may be significant. prescribing from the manual, pages 36-49.
Instructions Batch 2017
o Explain why it has to be taken for a week or
forever
Warnings
o When the drug should NOT be taken, what is
the maximum dose, and why the full
treatment course should be taken
Future consultations
Any questions?

How to Improve Patient Compliance to Treatment?

Prescribe a well chosen treatment

Create a good doctor patient relationship
Take time to give information, instructions and
warnings
o If the patient understands the importance of
the medication, he will comply

Transcribed By: Aaron Lalusin Page 4 of 4

Edited by: Lloyd Lim Formatted By: Aya Chang