CLINICAL Table 2: Eradication regimens (1) (15) for 7 days first and second line Penicillin allergy: Penicillin allergy &
previous metronidazole + clarithromycin:
PPI full dose bd PlUS amoxicillin 1g bd metronidazole 400mg bd PPI full dose bd
PlUS either clarithromycin bd aNd metronidazole 500mg bd OR
400mg bd PPI full dose bd PlUS
PlUS clarithromycin 250mg Bismuthate (de-nol tab®) 240mg bd PlUS
metronidazole 400mg bd PlUS tetracycline
hydrochloride 500mg qds do not use clarithromycin, metronidazole or quinolone if used in past year for any infection >
h2 receptor antagonist (h2Ra) may be used instead.
Peptic Ulcer disease (PUd) covers both gastric (in the stomach) ulcers and duodenal (small intestine) ulcers. an ulcer is an open sore that develops as ulceration of the mucosa of the stomach or duodenum, and is confirmed by endoscopic examination (1)
. Ulcers usually present
as a burning, gnawing feeling in the abdomen and can be quite painful; however they may also be painless but present as heartburn or indigestion. Stomach ulcers can affect people of any age, including children, but mostly occur in people aged 60 or over. men are more commonly affected than women (8)
. they can be
extremely dangerous and urgent medical attention should be sought if any of the following occur: • haematemesis (vomiting up blood) - may be large amounts and appear bright red or have a dark brown/grainy appearance, similar to coffee grounds. this would indicate that the blood has been in the stomach for a few hours • passing dark, sticky, tar-like stools • a sudden, sharp pain in the abdomen that gets steadily worse
these could be a sign of a serious complication, such as internal bleeding. It is caused by either bleeding at the site of the ulcer or perforation of the stomach lining which then could damage an underlying artery. It is important to determine whether the blood has come from the stomach or if the patient has coughed it up from the lungs (haemoptysis) (8)
.
the epidemiology of PUd is both helicobacter pylori (h. pylori) infection and the use of non-steroidal anti- inflammatory drugs (NSaIds). the incidence of h. pylori has been slowly
40 - PhaRmacy IN fOcUS
declining whereas NSaId use has been increasing. this has resulted in a decline in duodenal ulcers (almost always associated with h pyloriinfection) and an increase in gastric ulcers (the main site of ulcers caused by NSaIds (9)
).
about 40 per cent of people in the Uk have h pylori in their stomach, so it is very common and it is estimated that nine out of ten people who have it, do not experience any complications (10)
.
Endoscopic studies have shown a prevalence rate of between fourteen and 25 per cent of gastric and duodenal ulcers in NSaId users (11)
.
NSaIds interfere with the cyclo- oxygenase (cOx) pathways which lead to the production of prostaglandins. this interferes with mucosal protection in the lining of the stomach, therefore increasing the potential for stomach acid to irritate the stomach lining (11)
. this irritation,
over time, leads to the development of PUP.
therefore treatment of PUP is twofold. firstly it must be confirmed whether or not a h pylori infection is present. this can be carried out with a simple carbon-13 urea breath test. this is only available on prescription. It is carried out by the patient and sent off to a laboratory for determination of results. If the results return positive then an eradication therapy must begin (See table 2). If the result is negative, treat with a full-dose PPI for one or two months, depending on the reported severity of ulceration.
Secondly if the patient is on NSaIds then they should stop the NSaId if possible and test for h. pylori. If the test returns as a positive result, then
differential diagnosis: it is important to mention that there are similarities with the symptoms of dyspepsia and those associated with ischemic heart disease. heartburn can present itself as pain in the chest as can the signs of a myocardial infarction (mI). the important difference is that in mI, the pain is described as a sudden, crushing pain in the chest. also the patient is likely to have shortness of breath, a feeling of nausea and sweating. therefore cardiac disease history must be investigated in all patients and especially in those with unexplained chest pain (13)
.
as pharmacists we are more than likely to be the first point of contact for people experiencing dyspepsia symptoms. we are in the best position to offer advice to patients on how to ease their symptoms and on how to help prevent a reoccurrence of the condition. this includes lifestyle changes: through healthy diet and exercise, stopping smoking and general self-care.
Self-care examples would be to raise the head of their bed by putting solid/sturdy objects (wood/bricks) under the bed. additional pillows should not be used as a means to raise the patient up as this will only serve to compress the stomach. also having a main meal three to four
hours before going to bed may help (1)
. we can provide advice on using
Otc medication, offer help with prescribed medication and finally inform the patient about when to consult their gP. •
the patient should be started on a full dose PPI for eight weeks and then offered one week eradication therapy. If the result is negative then a full dose course of PPIs should be initiated for eight weeks (12)
.
Relapse & previous metronidazole + clarithromycin:
PPI full dose bd
PlUS amoxicillin 1g bd PlUS tetracycline
hydrochloride 500mg qds OR levofloxacin 250mg bd
Bibliography 1. Notes, cOmPaSS. cOmPaSS Notes Upper gI disorders.
https://www.medicinesni.com/assets/c OmPaSS/managementOfUppergIdisor ders.pdf. [Online] 2. guideline, NIcE. NIcE guidelines gORd and dyspepsia.
https://www.nice.org.uk/guidance/cg1 84. [Online] 3. QS, NIcE. NIcE Quality Standard.
https://www.nice.org.uk/guidance/QS 96/chapter/introduction. [Online] 4. choices, NhS. NhS choices Indigestion.
http://www.nhs.uk/conditions/indigest ion/pages/
introduction.aspx. [Online] 5. ckS, NIcE. ckS dyspepsia proven gORd.
http://cks.nice.org.uk/dyspepsia- proven-gord#!backgroundsub. [Online] 6. —. ckS causes of gORd.
http://www.nhs.uk/conditions/gastro esophageal-reflux- disease/Pages/
causes.aspx. [Online] 7. website, Emc. SPc alginates.
https://www.medicines.org.uk/emc/m edicine/24409. [Online] 8. choices, NhS. NhS conditions Peptic Ulcer.
http://www.nhs.uk/conditions/Peptic- ulcer/Pages/
Introduction.aspx. [Online] 9. Bmj. Bmj Epidemiology PUd.
http://bestpractice.bmj.com/best- practice/monograph/80/basics/epidemi
ology.html. [Online] 10. cORE, NhS in association with. NhS charity.
http://www.nhs.uk/ipgmedia/national/ core%20charity/assets/helicobacterpyl ori.pdf. [Online] 11. Russell, Bmj-R I. Non-steroidal anti-inflammatory drugs and gastrointestinal damage—problems and solutions.
http://pmj.bmj.com/content/77/904/82 .full. [Online] 12. ckS, NIcE. ckS Proven Peptic Ulcer.
http://cks.nice.org.uk/dyspepsia- proven-peptic-ulcer#!scenario. [Online] 13. choices, NhS. NhS heart attack Symptoms.
http://www.nhs.uk/conditions/heart- attack/Pages/
Symptoms.aspx. [Online] 14. formulary, British National. BNf Issue 70. 15. hPa,
gov.co.uk BIa and.
h.pylori update-British Infection association and health Protection agency.
https://www.gov.uk/government/uplo ads/system/uploads/attachment_data/f ile/346305/helicobacter_guidance_up date_post_maastricht_IV_24_10.pdf. [Online]
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