Chapter 37: Drug Therapy for Peptic Ulcer Disease PDF

Chapter 37 Drug Therapy for Peptic Ulcer Disease and Hyperacidity  Characterized by ulcer formation in the Peptic Ulcer esophagus, stomach, or duodenum areas of Disease the gastrointestinal (GI) mucosa that are exposed to gastric acid and pepsin...

Chapter 37 Drug Therapy for Peptic Ulcer Disease and Hyperacidity  Characterized by ulcer formation in the Peptic Ulcer esophagus, stomach, or duodenum areas of Disease the gastrointestinal (GI) mucosa that are exposed to gastric acid and pepsin Infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs (NSAIDs) account for most cases of peptic ulcer disease. Stress can precipitate ulcer formation. Gastric and duodenal ulcers are more common than esophageal ulcers. Gastric ulcers more often occur in older adults and are chronic in nature. Duodenal ulcers are strongly associated with H. pylori infection and NSAID use and can occur at any age. Copyright © 2025 Wolters Kluwer. All rights reserved. 2  Is the following statement True or False? Question #1 Peptic ulcers are found in the esophagus, stomach, and duodenum. Copyright © 2025 Wolters Kluwer. All rights reserved. 3  True Answer to Question #1 Rationale: Peptic ulcers are found in the esophagus, stomach, and duodenum. Gastric and duodenal ulcers are more common than esophageal ulcers. Copyright © 2025 Wolters Kluwer. All rights reserved. 4  Most common disorder of the esophagus Gastroesophageal Characteristics Reflux Disease oRegurgitation of gastric contents into the (GERD) #1 esophagus oExposure of esophageal mucosa to Gastric acid Pepsin Copyright © 2025 Wolters Kluwer. All rights reserved. 5  Characteristics (cont.) Gastroesophageal oAcid reflux Reflux Disease Often occurs after evening meal (GERD) #2 Decreases during sleep oPyrosis (heartburn; main symptom)  recumbent position, bending over oCommon during pregnancy, >40 years Copyright © 2025 Wolters Kluwer. All rights reserved. 6  Characteristics (cont.) Gastroesophageal oEffortless regurgitation of acidic fluid into Reflux Disease mouth, especially postmeal and at night (GERD) #3 Indicative of GERD Cause oIncompetent lower esophageal sphincter (LES) Copyright © 2025 Wolters Kluwer. All rights reserved. 7  Reflux-contributing factors Gastroesophageal oFoods Reflux Disease oFluids (GERD) #4 oMedications oGastric distention oCigarette smoking oRecumbent posture Copyright © 2025 Wolters Kluwer. All rights reserved. 8  Promote healing of lesions Medications for Prevent recurrence of lesions Upper GI o cell-destructive efforts Disorders o cell-protective efforts Several types oUsed alone and in various combinations Copyright © 2025 Wolters Kluwer. All rights reserved. 9  People commonly take over-the-counter (OTC) Antacids #1 antacids to offset the effects of GI acids. These drugs differ in their ability to neutralize gastric acid (50–80 mEq of acid is produced hourly), in onset of action, and in adverse effects. Commonly used antacids are mixtures of aluminum hydroxide and magnesium hydroxide, as well as other ingredients such as calcium salts (prototype: Mylanta; aluminum hydroxide-magnesium hydroxide- simethicone mixture). Calcium compounds may cause hypercalcemia and acid rebound. Copyright © 2025 Wolters Kluwer. All rights reserved. 10  Aluminum-containing antacids such as Antacids #2 Mylanta can cause constipation. In people who ingest large amounts of aluminum-based antacids over a long period, hypophosphatemia and osteomalacia may develop because aluminum combines with phosphates in the GI tract and prevents phosphate absorption. Aluminum compounds are rarely used alone for acid–peptic disorders. Mylanta also contains magnesium. Antacids with magnesium may cause diarrhea and hypermagnesemia. Older adults may experience neuromuscular effects. Copyright © 2025 Wolters Kluwer. All rights reserved. 11  Inhibit both basal secretion of gastric acid and Histamine2 the secretion stimulated by histamine, Receptor acetylcholine, and gastrin. Antagonists Common adverse effects of cimetidine (H2RA) (prototype) include diarrhea, dizziness, drowsiness, headache, confusion, and gynecomastia. They occur infrequently following the usual doses and standard duration of treatment. They are more likely with prolonged use of high doses, with increasing age, and with abnormal kidney function or impaired hepatic function. Copyright © 2025 Wolters Kluwer. All rights reserved. 12  Is the following statement True or False? Question #2 Strong inhibitors of gastric acid secretion. PPIs are similar to the H2RAs in terms of effects but have the same mode of action. Copyright © 2025 Wolters Kluwer. All rights reserved. 13  False Answer to Question #2 Rationale: Strong inhibitors of gastric acid secretion. PPIs are similar to the H2RAs in terms of effects but have a different mode of action. Copyright © 2025 Wolters Kluwer. All rights reserved. 14  Strong inhibitors of gastric acid secretion. PPIs Histamine2, (Omeprazole [prototype]) are similar to the Proton Pump H2RAs (Cimetidine) in terms of effects but Inhibitors (PPIs) have a different mode of action. Compared with H2RAs, PPIs suppress gastric acid more strongly, for a longer period. This effect provides faster symptom relief and faster healing in acid-related diseases. Copyright © 2025 Wolters Kluwer. All rights reserved. 15  Rates of ulcer recurrence are similar. Because Proton Pump PPIs are more effective than H2RAs, certainly Inhibitors (PPIs) in the short-term, PPIs are more popular. Adverse effects are reported with both short- and long-term use. Nausea, diarrhea, and headache are the most frequently reported adverse effects. High dose or long-term use of PPIs carry a possible increased risk of bone fractures due to hypocalcemia. Long-term use can affect absorption of dietary vitamin B12 and magnesium leading to deficiencies. Copyright © 2025 Wolters Kluwer. All rights reserved. 16  Naturally occurring prostaglandin E, which is Adjuvant produced in mucosal cells of the stomach and Medications #1 duodenum, inhibits gastric acid secretion and increases mucus and bicarbonate secretion, mucosal blood flow, and perhaps mucosal repair. It also inhibits the mucosal damage produced by gastric acid, aspirin, and NSAIDs. When synthesis of prostaglandin E is inhibited, erosion and ulceration of gastric mucosa may occur. Misoprostol approved for use with NSAIDs to protect gastric mucosa from NSAID-induced erosion and ulceration. Copyright © 2025 Wolters Kluwer. All rights reserved. 17  Sucralfate is a preparation of sulfated sucrose Adjuvant and aluminum hydroxide that binds to normal Medications #2 and ulcerated mucosa. Health care providers use it to prevent and treat peptic ulcer disease. For ulcer treatment, it requires use for 4 to 8 weeks unless healing is confirmed by radiologic or endoscopic examination. When used long term to prevent ulcer recurrence, dosage reduction is necessary. Copyright © 2025 Wolters Kluwer. All rights reserved. 18  Combination drug therapy that includes at Adjuvant least two antibiotics and an acid reducer Medications #3 (triple therapy), as well as occasionally bismuth subsalicylate (quadruple therapy), is recommended for patients with peptic ulcer disease who are known to be infected with H. pylori. Copyright © 2025 Wolters Kluwer. All rights reserved. 19  Health care providers use bismuth Adjuvant subsalicylate to coat ulcers, protecting them Medications #4 from stomach acid to treat H. pylori. Other uses include treatment of diarrhea and nausea. Bismuth subsalicylate can cause serious bleeding problems when used alone in patients with ulcers. Copyright © 2025 Wolters Kluwer. All rights reserved. 20  Identify risk factors for peptic ulcer disease. Assessment #1 oCigarette smoking. Effects are thought to include stimulation of gastric acid secretion and decreased blood supply to gastric mucosa. (Nicotine constricts blood vessels.) Moreover, patients with peptic ulcers who continue to smoke heal more slowly and have more recurrent ulcers, despite usually adequate treatment, than those who stop smoking. Copyright © 2025 Wolters Kluwer. All rights reserved. 21  Identify risk factors for peptic ulcer disease Assessment #2 (cont.). oStress, including physiologic stress (e.g., shock, sepsis, burns, surgery, head injury, severe trauma, medical illness) and psychological stress. One mechanism may be that stress activates the sympathetic nervous system, which then causes vasoconstriction in organs not needed for “fight or flight.” Thus, stress may lead to ischemia in gastric mucosa, with ulceration if ischemia is severe or prolonged. Copyright © 2025 Wolters Kluwer. All rights reserved. 22  Identify risk factors for peptic ulcer disease Assessment #3 (cont.). oDrug therapy with aspirin and other NSAIDs, corticosteroids, and antineoplastic Assess for signs and symptoms, which depend on the type and location of the ulcer. Copyright © 2025 Wolters Kluwer. All rights reserved. 23  Assess for signs and symptoms, which depend Assessment #4 on the type and location of the ulcer (cont.). oPeriodic epigastric pain, which occurs 1 to 4 hours after eating or during the night and is often described as “burning” or “gnawing,” is a symptom of a chronic duodenal ulcer. oGI bleeding, this occurs with acute or chronic ulcers when the ulcer erodes into a blood vessel. Clinical manifestations may range from mild to severe. oGERD, which produces heartburn. Copyright © 2025 Wolters Kluwer. All rights reserved. 24  Use measures to prevent or minimize peptic Nursing ulcer disease and gastric acid–induced Interventions #1 esophageal disorders. With peptic ulcer disease, helpful interventions may include the following: oGeneral health measures such as a well- balanced diet, adequate rest, and regular exercise Copyright © 2025 Wolters Kluwer. All rights reserved. 25  Avoiding cigarette smoking and gastric Nursing irritants (e.g., alcohol, aspirin and NSAIDs, Interventions #2 caffeine) Reducing psychological stress (e.g., by changing environments) or learning healthful strategies of stress management (e.g., relaxation techniques, physical exercise). There is no practical way to avoid psychological stress because it is part of everyday life. Copyright © 2025 Wolters Kluwer. All rights reserved. 26  Long-term drug therapy with small doses of Nursing H2RAs, antacids, or sucralfate. With “active” Interventions #3 peptic ulcer disease, helping the patient follow the prescribed therapeutic regimen helps to promote healing and prevent complications. Diet therapy is of minor importance in prevention or treatment of peptic ulcer disease. Some physicians prescribe no dietary restrictions, whereas others suggest avoiding or minimizing highly spiced foods, gas-forming foods, and caffeine-containing beverages. Copyright © 2025 Wolters Kluwer. All rights reserved. 27  With heartburn and esophagitis, helpful Nursing measures are those that prevent or decrease Interventions #4 gastroesophageal reflux of gastric contents (e.g., avoiding irritant, highly spiced, or fatty foods; eating small meals; not lying down for 1 to 2 hours after eating; elevating the head of the bed; avoiding obesity, constipation, or other conditions that increase intra-abdominal pressure). Copyright © 2025 Wolters Kluwer. All rights reserved. 28