Gastroenterology:
Peptic Ulcer Disease
Courses in Therapeutics and Disease State Management
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Learning Objectives
• Identify and compare the common forms of peptic ulcer
disease (PUD).
• Describe features associated with Helicobactor pyloriassociated and NSAID-induced ulcers.
• Discuss the role of Helicobacter pylori (HP) in PUD.
• Compare and contrast signs and symptoms of duodenal and
gastric ulcers.
• Identify, describe, and discuss the utility of laboratory tests
used to detect the presence of HP
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Learning Objectives
• Discuss pharmacologic treatment options for HPassociated and NSAID-induced PUD.
• Given a PUD patient history, recommend appropriate
pharmacologic therapy and explain the rationale behind
your decision
• Discuss drug adverse effects and monitoring parameters
for drugs and disease states
• Construct counseling points for a PUD patient on their
disease state and pharmacologic therapy
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Required Reading
Love BL, Mohorn PL. Peptic Ulcer Disease and Related
Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR,
Wells BG, Posey L. eds. Pharmacotherapy: A
Pathophysiologic Approach, 10e New York, NY: McGrawHill; 2017.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Overview
• Peptic ulcer disease (PUD) refers to ulceration of the
mucosa anywhere in the GI tract exposed to acid and
pepsin
• They can range in size from a few millimeters to a few
centimeters
• Estimated that 10% of Americans will develop PUD in
their lifetime
• The 2 most common forms/locations of PUD are
– Duodenal ulcer
– Gastric ulcer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Duodenal Ulcers
• Most common form of PUD
– It is 3 times more common than gastric ulcers
• Usually located in the duodenal bulb of the small intestine
• Most commonly occurs in people between the ages of 30
and 50
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Gastric Ulcers
• Less common than duodenal ulcers
– Especially in the absence of chronic NSAID use
• Most commonly located in the lesser curvature of the
antrum of the stomach
• More common in people greater than 60 years old
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Duodenal and Gastric Ulcers
Link: Anatomic structure of the stomach and duodenum
and most common locations of gastric and duodenal ulcers.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Duodenal and Gastric Ulcers
• Link: Figure of a Duodenal Ulcer
• Link: Figure of a Duodenal Ulcer and a Gastric Ulcer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Etiology and Pathophysiology
• Gastric and duodenal ulcers develop because of an
imbalance between aggressive factors and mechanisms
that maintain mucosal integrity
• There is an increase in mucosal injury and a decrease in
mucosal defense
– Aggressive factors (H. pylori, NSAIDs) cause mucosal injury
and a decrease in mucosal defenses and healing (decreased
mucous, decreased bicarbonate, decreased mucosal blood
flow)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Etiology and Pathophysiology
• Common causes of PUD
– Helicobacter pylori (H.pylori) infection
– Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
– Critical illness (stress-related mucosal damage)
• Uncommon causes of PUD
–
–
–
–
–
Idiopathic (non-H.pylori, non- NSAID)
Hypersecretion of gastric acid (e.g. Zollinger Ellison syndrome)
Viral infections
Radiation therapy
Chemotherapy
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Helicobacter Pylori (HP)-Associated
• Helicobacter pylori (HP) is a spiral shaped, gram
negative, flagellated bacteria first associated with PUD in
the early 1980’s
• Found in most people with duodenal and gastric ulcers
– About 95% of those with duodenal ulcers
– About 80% of those with gastric ulcers
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Helicobacter Pylori (HP)-Associated
• Approximately 30% - 40% of the U.S. population is
infected
• About 15% of those infected will develop PUD
• HP is primarily spread through the fecal to oral route
• People are most often infected during childhood
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Helicobacter Pylori (HP)-Associated
• Mechanisms by which HP causes mucosal injury are not
entirely clear but occurs through a combination of the
following mechanisms:
– HP catalyzes urea  ammonia is produced  ammonia erodes
the mucous barrier and causes epithelial damage
– HP produces cytotoxins
– HP produces mucolytic enzymes
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Helicobacter pylori (HP)-Associated
Link: Schematic of the relationships between colonization
with Helicobacter pylori and diseases of the upper
gastrointestinal tract
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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NSAID-Induced
• In long-term NSAID users, there is a 10% - 20%
prevalence of gastric ulcers and a 2% - 5% prevalence of
duodenal ulcers
• Mechanisms for NSAID-induced ulceration
– NSAIDs are weak acids and are non-ionized at gastric pH
• Diffuse freely across the mucous barrier into gastric epithelial cells 
H+ ions are liberated and cause cellular damage
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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NSAID-Induced
• Mechanisms for NSAID-induced ulceration (continued)
– NSAIDs inhibit cyclooxygenase activity and therefore decrease
prostaglandin production which results in a:
• Reduction in gastric and mucosal blood flow
• Decrease in mucous and bicarbonate secretion
• Decrease in cellular repair and replication
• Link: Figure showing mechanisms by which nonsteroidal
anti-inflammatory drugs may induce mucosal injury
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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NSAID-Induced
• 1% - 2% of NSAID users will develop an ulcer or ulcer
complications with 1 year
• The risk of developing an NSAID-related complication is
greater in patients:
– Greater than 60 years old
– With a prior history of PUD
– Taking high dose NSAIDs or multiple NSAIDs, including low
dose aspirin
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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NSAID-Induced
• The risk of developing an NSAID-related complication is
greater in patients (continued):
– Who are concurrently taking
•
•
•
•
•
Corticosteroids
Anticoagulants
Oral bisphosphonates
Anti-platelet agents
SSRIs (Selective Serotonin Reuptake Inhibitors)
• Aspirin is the most ulcernogenic of all NSAIDs.
– Even with low dose aspirin (81-162mg/day), ulcers occur in 0.6% 1.2% of patients per year.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Zollinger-Ellison Syndrome (ZES)
• ZES is characterized by gastric acid hypersecretion and
recurrent peptic ulcers that result from a gastrin-producing
tumor
– More than 50% of gastrinomas are malignant
• ZES is suspected for patients with multiple ulcers and
recurrent or refractory PUD often accompanied by
esophagitis or ulcer complications
• Only accounts for 0.1% to 1% of those with duodenal
ulcer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Other Potential Factors in the
Development of PUD
• Cigarette smoking
– Increases the risk of developing PUD and its complications
– Impairs ulcer healing and increases the risk of recurrence
– Ulcer risk is proportional to the number of cigarettes smoked per day
• Psychological stress
– People who develop PUD tend to be more adversely affected by stress
– However, controlled trials are conflicting and have failed to document a direct
cause-effect relationship
– Stress may induce behavioral risks such as smoking and the use of NSAIDs or
may alter the inflammatory response or resistance to HP infection
• Dietary factors
– Certain foods (e.g. coffee, tea, carbonated beverages, beer, milk, spices) may
cause dyspepsia but do not increase the risk of developing PUD
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Signs and Symptoms
• Symptoms depend on ulcer location, ulcer etiology, and
patient age
• Many patients, particularly the elderly, have few or even
no symptoms
• NSAID-induced ulcers are often silent
– Complications such as bleeding and perforation are often the
initial presentation
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Signs and Symptoms
• Pain localized to the epigastrium is the most common
symptom
• The pain is described as burning, gnawing, cramping, or
hunger
• A typical nocturnal pain that wakes the patient from sleep
(especially between 12 and 3am)
• The severity of ulcer pain varies from patient to patient
and my be seasonal, occurring more often in the spring or
fall
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Signs and Symptoms
• Episodes of pain usually occur in clusters, lasting up to a
few weeks followed by a pain-free period or remission
lasting weeks to years
• Changes in the character of pain may suggest the
presence of complications
• Pyrosis (heartburn), belching, and bloating may
accompany the pain
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Gastric Ulcer
• Pain often does not follow a consistent pattern; not
predictable
• Food will sometimes cause or accentuate pain
• Nausea, vomiting, anorexia, and weight loss are more
common with gastric ulcer than duodenal ulcer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Duodenal Ulcer
• Pain more likely follows a consistent pattern (compared to
gastric ulcer)
– Epigastric pain occurs in 60% - 90% of patients with duodenal
ulcers
• Food often relieves pain but the pain usually returns 1 to 3
hours after eating
• Nocturnal epigastric pain often occurs
• 40% - 70% have additional non-specific dyspeptic
complaints (belching, bloating, abdominal distension, food
intolerance)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Clinical Presentation
• Link: Table on Comparison of Common Forms of Peptic
Ulcer
• Link: Table on Clinical Presentation of Peptic Ulcer
Disease
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Complications
• Major complications of PUD include:
– Bleeding
• Occurs in about 15% of patients with active PUD
– Perforation
• Occurs in about 7% of patients with active PUD
– Mortality
• Mortality from acute bleeding is about 6% - 10%
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Bleeding and Hemorrhage in Peptic Ulcers
Link: Figure of stigmata of hemorrhage in peptic ulcers
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Role of Testing
• The diagnosis of PUD depends on visualizing the ulcer
crater by either upper GI radiography or upper endoscopy
– Upper GI radiography with barium was the initial diagnostic
procedure but has been replaced with upper endoscopy
• There are multiple laboratory tests that can be performed
to diagnosis an H.pylori infection
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Testing for H. pylori
• There are multiple tests that can be performed to test for the
presence of H. pylori
• Invasive testing (Requires endoscopy with biopsy)
– Histology
– Culture
– Rapid urease testing
• Noninvasive testing
– Serological test
– Urea breath test
– Fecal antigen test
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Invasive Testing
• All of these tests require biopsy to be acquired via
endoscopy
• Histology
– Microbiologic examination using various stains
– Excellent sensitivity and specificity but it is invasive, expensive
and requires trained personnel
• Culture
– Culture of biopsy
– Costly, time consuming, and technically difficult
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Invasive Testing
• Rapid Urease Testing
– Rapid urease tests detect the presence of ammonia in the
biopsy sample
– The ammonia is generated by H.pylori urease activity
– Test of choice at endoscopy
– Greater than 90% sensitive and specific
– Easily performed with rapid results
– Tests for active HP infection
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Noninvasive Tests
(Antibody Detection/Serological Test)
• A simple blood test
– Laboratory-based (more accurate than office-based tests)
– Office-based
• Detects IgG antibodies to H. pylori in the serum
• Quick, noninvasive, inexpensive but has a low positive
predictive value in populations where prevalence of HP
infection is low.
• Can’t be used to distinguish between an active infection or
past exposure because antibodies persist for long periods of
time
– Most patients remain seropositive for 6 months to 1 year after HP
eradication
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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• Can’t be used to determine if eradication is successful
Noninvasive Tests (Urea Breath Test)
• Detects the exhalation of radioactive CO2 following
ingestion of 13C or 14C radiolabeled urea
• H. pylori hydrolysis of the radiolabeled urea results in
radiolabeled CO2 production
• 97% sensitivity and 95% specificity
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Noninvasive Tests (Fecal Antigen Test)
• Polyclonal antibody test that detects the presence of
H.pylori antigen in the stool
• Sensitivity and specificity similar to urea breath test
• Patients may have a reluctance to collect stool samples
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Noninvasive Tests
• The urea breath and fecal antigen tests may be falsely
negative in patients who have recently taken
– Antibiotics (up to 4 weeks)
– Bismuth compounds (up to 4 weeks)
– Antisecretory agents (up to 2 weeks)
• The urea breath and fecal antigen tests can be used as
an initial screen to determine if a patient is infected
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Tests for Confirming Eradication
• The urea breath (preferred) and fecal antigen tests can be
used to confirm eradiation of H.pylori in a patient who has
been treated
• The serological test can not be used to determine eradication
because antibodies last for an extended period after the
infection has been cleared
• However, confirming eradication is not practical or cost
effective
• Indications for confirming eradication include:
– Continued dyspeptic symptoms
– H. pylori-associated MALT (mucosal associated lymphoid tissue)
lymphoma
– Resection for gastric cancer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Testing for H. pylori
Link: Table covering tests for the detection of
Helicobacter pylori
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment/Therapy Goals
• Choice of treatment depends on etiology (e.g. HP or
NSAIDs) and whether treatment is for initial management
or prevention of recurrence
• Overall goals
– Relief of pain
– Healing of ulcer
– Prevention of recurrence
– Prevent or reduce complications
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Nonpharmacologic Therapy
•
•
•
•
Eliminate or reduce psychological stress
Smoking cessation
Eliminate or reduce NSAID use
Avoid foods that cause dyspepsia
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Pharmacologic Therapy Overview
• For an active HP positive ulcer, our goals are to eradicate the
HP, heal the ulcer, and ultimately cure the disease
– Use multi-drug regimens containing antibiotics and anti-secretory
agents (usually proton pump inhibitors (PPIs)) and sometimes
bismuth preparations
• For an NSAID-induced peptic ulcer or a peptic ulcer is not
caused by HP, our primary goal is to heal the ulcer as quickly
as possible
– Can use PPIs, H2-receptor antagonists, or sucralfate
– Antacids are not used as monotherapy to heal peptic ulcers
– Misoprostol can be used to reduce the risk of NSAID-induced PUD
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Proton Pump Inhibitors (PPIs)
• MOA
– Blocks acid secretion by inhibiting gastric H+/K+ adenosine triphosphatase found
on the secretory surface of gastric parietal cells
– Results in a long-lasting anti-secretory effect that can maintain gastric pH levels
above 4
• Agents
–
–
–
–
–
–
–
Dexlansoprazole (Dexilant)
Esomeprazole (Nexium)
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
Omeprazole/sodium bicarbonate (Zegerid)
Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Proton Pump Inhibitors (PPIs)
• Common adverse effects
– Headache, dizziness, somnolence, diarrhea, constipation,
flatulence, abdominal pain, nausea
• Serious adverse effects
– Increased risk of Clostridium difficile infections
– Increase risk of community-acquired pneumonia
• Long-term adverse effects (> 1 year)
– Hypomagnesemia
– Bone fractures
– Vitamin B12 deficiency
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Proton Pump Inhibitors (PPIs)
• Monitoring
– Appearance of diarrhea (frequency and type of diarrhea episodes)
– Periodic magnesium levels (if long-term therapy)
– Routine bone density studies (DXA scans)
• If other risk factors for osteoporosis or bone fractures present
• Patient counseling
– Preferable to take a PPI 30 to 60 minutes before a meal (mainly
breakfast)
– If a second dose is needed, take prior to the evening meal
– Onset of relief is 2 to 3 hours and the duration of relief is 12 to 24
hours
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Evaluate the Risks versus Benefits of
Long-Term PPI Use
• Long-term PPI use has been associated with increased
risk of:
– Fractures
– Infections such as C. Diff and pneumonia (expand)
– Hypomagnesemia
– Vitamin B12 deficiency
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Evaluate the Risks versus Benefits of
Long-Term PPI Use
• Long-term PPI use MAY BE associated with increased
risk of:
– Dementia
– Renal disease
– Cardiovascular disease
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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H2-Receptor Antagonists
• MOA
– Competitive inhibition of histamine at H2 receptors of gastric
parietal cells which inhibits gastric acid secretion
• Agents
– Cimetidine (Tagamet)
– Famotidine (Pepcid)
– Nizatidine (Axid)
– Ranitidine (Zantac)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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H2-Receptor Antagonists
• Adverse effects
– Headache, somnolence, fatigue, dizziness, constipation,
diarrhea
• Monitoring
– Monitor for CNS effects (rare) in those over 50 years old or in
those with renal or hepatic impairment
• Patient counseling
– If taking once a day, it is preferable to take the dose at bedtime
– Onset of relief is 30 to 45 minutes and duration of relief is 4 to
10 hours
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Misoprostol
• MOA
– A synthetic prostaglandin E1 analog that replaces the protective
prostaglandins that are decreased from prostaglandin inhibiting
therapies such as NSAIDs
• Enhances natural gastromucosal defense mechanisms and healing by
increasing the production of gastric mucous and mucosal secretion of
bicarbonate
• Inhibits basal and nocturnal acid secretion by direct action on the parietal
cells
• Agent
– Misoprostol (Cytotec)
• Adverse effects
– Diarrhea, abdominal pain, headache, nausea/vomiting, flatulence,
dysmenorrhea, hypophosphatemia
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Misoprostol
• Monitoring
– Pregnancy test
– Serum phosphate
• Patient Counseling
– Pregnancy category X
• Is a potential abortifacient
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Bismuth Preparations
• MOA
– Bismuth exhibits antimicrobial activity against bacterial and viral
gastrointestinal pathogens
• Agents
– Bismuth subsalicylate (Pepto-Bismol and others)
– Bismuth subcitrate potassium (bismuth salt in Pylera capsules)
• Adverse effects
– Fecal discoloration, tongue discoloration
– Neurotoxicity (rare)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Bismuth Preparations
• Monitoring
– No specific monitoring
• Patient counseling
– May cause temporary, harmless darkening of the tongue and/or
stool
– Avoid bismuth subsalicylate if have an aspirin allergy
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Sucralfate
• MOA
– Thought to form an ulcer-adherent complex at the ulcer site
protecting it from further injury from stomach acid
• Agent
– Sucralfate (Carafate)
• Adverse Effects
– Constipation, bezoar formation, hyperglycemia in diabetes
patients, aluminum toxicity in patients with chronic renal failure
or on dialysis
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Sucralfate
• Monitoring
– Blood glucose in diabetes patients
– Renal function in elderly patients
• Patient counseling
– Take on an empty stomach
– Do not take antacids 30 minutes before or after taking
sucralfate
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Antacids
• MOA
– Neutralize hydrochloric acid in the stomach, which results in an increase
in gastric pH
• Agents
– Magnesium hydroxide
– Aluminum hydroxide
– Calcium carbonate
• Adverse effects
–
–
–
–
Diarrhea (magnesium hydroxide)
Constipation (aluminum hydroxide and calcium carbonate)
Alterations in mineral metabolism
Acid-base disturbances
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Antacids
• Monitoring
– Periodic calcium and phosphate levels if on chronic antacid therapy
• Patient counseling
– Antacids can decrease the levels of numerous other drugs including
tetracyclines, digoxin, iron supplements, fluroquinolones, and
ketoconazole.
• Patients should separate antacids and other medications by at least 2 hours
– Patients with renal impairment should not use aluminum or magnesium
containing antacids unless directed by their physician
– Onset of relief is less than 5 minutes and duration of relief is 20 to 30
minutes
• Link: Table on Composition and Acid Neutralizing Capacities of
Popular Antacid Preparations
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Drug Used in PUD Therapy Regimens
• Link: Drug Dosing Table
• Link: Drug Monitoring Table
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of H. pylori-Positive Ulcers
• Multi-drug regimens that include antimicrobials and anti-secretory agents are used
to eradicate H. pylori infection
• H. pylori has been developing resistance to some antibiotics, particularly
clarithromycin
– First-line therapies should have an eradication rate of greater than 80%
– Regional bacterial resistance patterns need to be taken into account when
recommending therapy
– If a second course of H. pylori eradication therapy is needed, the second regimen should
contain different antibiotics
• H.pylori eradication regimens
–
–
–
–
Triple Therapy
Bismuth-based Quadruple Therapy
Sequential Therapy
Salvage Therapy
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Triple Therapy
• Standard triple therapy regimen contains
– Amoxicillin 1000mg twice day PLUS Clarithromycin 500mg
twice a day PLUS a PPI dosed once to twice a day
– Given for 10 to 14 days
• 14 day regimens are generally preferred as 14 day regimens
significantly increases the eradication rate
• If the patient is allergic to penicillin, then metronidazole
500mg twice a day can be substituted for the amoxicillin
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Triple Therapy
• Standard triple therapy is considered first-line in areas
where the clarithromycin resistance rate of H. pylori is
less than 20%
• Adding probiotics (specifically Saccharomyces boulardii
and Lactobacillus) to triple therapy has been shown to
increase eradication rates and decrease adverse effects
of treatment, particularly diarrhea
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Bismuth-based Quadruple Therapy
• Bismuth-based quadruple-therapy contains
– Tetracycline 500mg 4 times day PLUS Metronidazole 250500mg 4 times a day PLUS Bismuth subsalicylate 525mg 4
times a day PLUS a PPI once or twice a day OR H2-receptor
antagonist twice a day
– Pylera is a brand name product that is a 3 in 1 capsule
• Each capsule contains Tetracycline 125mg, Metronidazole 125mg, and
Bismuth subcitrate potassium 140mg
• Dose is 3 capsules 4 times a day plus a PPI twice a day
– Bismuth-based quadruple regimens are given for 10 to 14 days
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Bismuth-based Quadruple Therapy
• May be used as first-line therapy in areas where the
clarithromycin resistance rate is ≥ 20%
• May also be considered for first-line therapy in those with
penicillin allergy or in those who have been previously
treated with a macrolide antibiotic
• May also be used if first-line standard triple therapy fails
(e.g. as second-line therapy or salvage therapy)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Sequential Therapy
• Newer HP eradication therapy where the antibiotics are
administered in a sequence rather than at the same time
• Sequential therapy contains:
– A PPI twice a day for 10 days AND
– Amoxicillin 1000mg twice day days 1 – 5, followed by
Clarithromycin 500mg twice day PLUS Tinidazole 500mg OR
Metronidazole 500mg twice a day days 6 – 10.
– Given for 10 days total (5 days for each antibiotic regimen)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Sequential Therapy
• Adherence and tolerance rates of sequential therapy are
similar to triple therapy but the cost is lower
• The American College of Gastroenterology (ACG)
Guidelines state that additional validation of sequential
therapy needs to occur in North America before it is
recommended as a first-line regimen
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Levofloxacin-Based Triple Therapy
• Levofloxacin-based Triple Therapy contains:
– Amoxicillin 1000mg twice a day PLUS Levofloxacin 500mg
once a day PLUS a PPI twice a day
– Given for 10 days
• This regimen is an option for salvage therapy in patients
who have persistent H. pylori infection
– This therapy regimen needs validation in North America
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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PPI after H. pylori Eradication Therapy
Completion
• When treating an active ulcer, anti-secretory therapy with
a PPI is usually continued for 2 weeks after completing
the eradication therapy regimen
• Typically PPI treatment beyond 2 weeks after completion
of eradication therapy is not needed for ulcer healing
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of NSAID-Induced Ulcers
• Ideally, discontinue the NSAID and treat with standard
healing regimens of a PPI, H2-receptor antagonist, or
sucralfate
– Link: Drug Dosing Table
– PPIs are usually preferred because they provide the fastest
symptom relief and ulcer healing
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of NSAID-Induced Ulcers
• If the NSAID needs to be continued:
– Consider:
• Reducing the dose of the NSAID OR
• Change NSAID to one of the following
– Acetaminophen
– A nonacetylated salicylate (salsalate, trisalicylate)
– A partially selective COX-2 inhibitor (etodalac, nabumetone, meloxicam,
diclofenac, celecoxib)
– Use a PPI to treat the ulcer
• When an NSAID needs to be continued, PPIs are the drugs of choice
to treat and heal the ulcer
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Reducing the Risk of NSAID-Induced
Ulcer and GI Complications
• Strategies to reduce the risk of NSAID-induced ulcers
– In GI toxicity high risk patients, use either a PPI or misoprostol
as co-therapy along with the NSAID
– Use a selective COX-2 inhibitor instead of a nonselective
NSAID
• When selecting a strategy, cardiovascular risk of the
patient must also be considered
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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GI and Cardiovascular Safety Issues with
NSAIDs
• There is no difference in cardiovascular risk between the
selective COX-2 inhibitors, the partially selective NSAIDs,
and the non-selective NSAIDs with the exception of
naproxen
– When compared with all the other NSAIDs, naproxen has the
best cardiovascular safety profile
• Link: Table on Risk Factors Associated with NSAIDInduced Ulcers and Upper GI Complications
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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GI and Cardiovascular Safety Issues with
NSAIDs
• Guidelines for reducing GI risk for patients receiving
chronic NSAID therapy
– Link: Table on Guidelines for Reducing GI Risk for Patients
Receiving Chronic NSAID Therapy
• Guidelines take both CV risk and GI toxicity risk into account when
recommending a strategy to reduce the risk of developing a peptic
ulcer in those who need chronic NSAID therapy
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of Non-H. pylori, Non-NSAID Ulcers
• Very few patients have non-H. pylori, non-NSAID
(idiopathic) peptic ulcers
• If an idiopathic peptic ulcer is confirmed, treatment with
standard ulcer healing therapy should be initiated
– Standard H2-receptor antagonist or sucralfate dosage regimens
heal the majority of gastric and duodenal ulcers in 6 to 8 weeks
– Standard PPI dosage regimens heal the majority of gastric and
duodenal ulcers in 4 weeks
– Link: Drug Dosing Table
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Maintenance Therapy with Anti-Secretory
Agents
• Maintenance therapy (to maintain ulcer healing, prevent
recurrence and complications) with anti-secretory agents like
PPIs is only indicated in the following groups of high risk
patients:
– Those who have failed H. pylori eradication
– Those who have a history of ulcer related complications
– Those who have frequent recurrences of H. pylori-negative ulcers
– Those who are heavy smokers
– Those who NSAID users
• Standard maintenance doses as listed in Drug Dosing Table are
appropriate for most of these patients
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of Gastric Acid Hypersecretion from
Zollinger-Ellison Syndrome (ZES)
• PPIs are the oral drugs of choice for managing gastric
acid hypersecretion from ZES
• Treatment should be started with omeprazole 60mg per
day or an equivalent dose of another PPI
– This PPI daily dose should be divided and the PPI given every
8 to 12 hours
• Additional pharmacologic and non-pharmacologic
treatments are instituted depending on the gastrinoma
itself and any other complications that may be present
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Treatment of Refractory Ulcers
• Ulcers are considered refractory to therapy when
symptoms, ulcers, or both persist beyond 8 to 12 weeks
despite conventional treatment as previously described or
when several courses of H. pylori eradication therapy fail
• Patient should undergo an upper endoscopy to assess
the situation
• Treatment depends on cause and may include additional
H. pylori eradication attempts, higher PPI dosages, or
surgery
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Evaluation and Management of PUD
Link: Algorithm for the evaluation and
management of PUD
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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Additional Patient Counseling
• Discuss with the patient the cause of the ulcer (e.g. H.
pylori, NSAIDs, etc.)
• Address risk factors (e.g. NSAID use, cigarette smoking,
etc.)
• Discuss the rationale behind the multi-drug regimens and
the importance of adherence and sticking to the full
course of therapy
• Caution patient to look out for signs of GI bleeding (e.g.
tarry stools, abdominal pain, vomiting with evidence of
blood)
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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References
• Atherton JC, Blaser MJ. Helicobacter pylori Infections. In: Kasper D,
Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s
Principles of Internal Medicine, 19e. New York, NY; McGraw-Hill;
2015.
• Kee Song L, Topazian M. Gastrointestinal Endoscopy. In: Kasper D,
Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's
Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill;
2015.
• Del Valle J. Peptic Ulcer Disease and Related Disorders. In: Kasper
D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds.
Harrison's Principles of Internal Medicine, 19e. New York, NY:
McGraw-Hill; 2015.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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References
• Love BL, Thoma MN. Chapter 20. Peptic Ulcer Disease. In: DiPiro
JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds.
Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY:
McGraw-Hill; 2014.
• Wallace JL, Sharkey KA. Pharmacotherapy of Gastric Acidity, Peptic
Ulcers, and Gastroesophageal Reflux Disease. In: Brunton LL,
Chabner BA, Knollmann BC. eds. Goodman & Gilman's: The
Pharmacological Basis of Therapeutics, 12e. New York, NY:
McGraw-Hill; 2011.
• Martin CP, Talbert RL. Section 5. Gastroenterology. In: Martin CP,
Talbert RL. eds. Pharmacotherapy Bedside Guide. New York, NY:
McGraw-Hill; 2013.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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References
• Chey WD, Wong B, et al. American College of
Gastroenterology Guideline on the Management of
Helicobacter pylori Infection. Am J Gastroenterol 2007; 102:
1808-1825.
• Graham DY, Fischbach L. Helicobacter pylori treatment in the
era of increasing antibiotic resistance. Gut 2010; 59: 11431153.
• Rimbara E, Rischbach LA, Graham DY. Optimal therapy for
Helicobacter pylori infections. Nat Rev Gastroenterol Hepatol
2011; 8: 78-88.
• Chuah SK, Tsay FW, Hsu PI, Wu DC. A new look at antiHelicobacter pylori therapy. World J Gastroenterol 2011; 17:
3971-3975.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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References
• Micromedex Solutions. Truven Health Analytics, Inc. Ann
Arbor, MI. Accessed November 1, 2016.
• Lexicomp Online®, Lexi-Drugs®, Hudson, Ohio: LexiComp, Inc. Accessed November 1, 2016.
Author: Monica L. Skomo, B.S., Pharm.D., BCACP, CTTS; Assoc. Prof. of Pharmacy Practice; Dir. of Assessment and Educational Strategies; Duquesne University School of Pharmacy
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