Chapter 32 Supplemental

8/17/2019 Chapter 32 Supplemental

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Workbook and Casebook for Goodman and Gilman's The Pharmacological Basis of Therapeutics >

Chapter 32: Pharmacotherapy of Gastric Acidity, Peptic Ulcers, and GastroesophagealReux isease

!"#R$UC#!$" This chapter will be most useful after having a basic understanding of the material in Chapter 4! Pharmacotherap"

of Gastric #cidit"! Peptic $lcers! and Gastroesophageal %e&u (isease in Goodman & Gilman's The PharmacologicalBasis of Therapeutics! )*th +dition, -n addition to the material presented here! the )*th +dition contains.

• # description of the ph"siolog" of gastric secretion

• Therapeutic strategies for the treatment of speci/c acid0peptic disorders

• Table 40* which shows the composition and acid neutrali1ing capacities of popular antacid preparations

%&AR"!"G $'(&C#!)&*• -dentif" the sites in the gastric parietal cell where drugs act to suppress acid secretion,

• (escribe the mechanism of action of proton pump inhibitors! 2* receptor antagonists! andprostaglandin analogs to suppress gastric acid secretion,

• (escribe the limitations to the use of 2* receptor antagonists in chronic acid suppression,

• -dentif" potential drug interactions with proton pump inhibitors and 2* receptor antagonists,

• (escribe the mechanism of action of drugs that enhance gastric c"toprotection,

• (escribe the recommendations for therap" of gastroesophageal re&u disease 3G+%( andpeptic ulcer disease,

• $nderstand the role of Helicobacter pylori infection in peptic ulcer disease and the therapeuticprinciples for its eradication,

• (escribe appropriate therap" for 56#-(0induced ulcers,

(%$G6 -5C7$(+( -5 T2-6 C2#PT+%Cimetidine 3T#G#8+T! others (elansopra1ole 39#P-(+: +somepra1ole 35+:-$8;amotidine 3P+P6-(! others 7ansopra1ole 3P%+


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RUG C%A** RUG* +&CA"!*+ $- AC#!$"

+somepra1ole(elansopra1ole%abepra1ole

Prostaglandin#nalog 8isoprostol Binds to the +P@ receptor on parietal cells decreasing c"clic #8Pand gastric acid secretion 3see ;igure @*0)

C"toprotective#gent

6ucralfate;orms a viscous! stick" pol"mer that adheres to epithelial cellsand ulcer craters and is c"toprotective

#ntacids


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d, !f the patient is s1itched to a proton pump inhiitor, of 1hat ad5ersee6ects should she e 1arnedProton pump inhibitors are metaboli1ed b" hepatic C=Ps and the" ma" interfere withthe elimination of other drugs cleared b" this route, Chronic treatment with protonpump inhibitors decreases the absorption of vitamin B)*, The loss of gastric acidit"ma" aect the bioavailabilit" of drugs! most notabl" iron salts, This ma" result in an

iron de/cienc" anemia,

-!GUR&32.7

Generalguidelinesfor themedical

management of gastroesophageal re&u disease 3G+%(, nl" medications that suppressacid production or that neutrali1e acid are shown,

CA*& 32.2# F0"ear0old man is diagnosed with duodenal ulcer complicated b" H. pylori infection, 2ehas been treated with amoicillin for * weeks! but his s"mptoms of stomach pain persist,

a, 0hy has his therapeutic regimen not een e6ecti5e 0hatprolems might e the result of this therapeutic regimenH. pylori! a gram negative rod! has been associated with gastritis and subseDuentdevelopment of gastric and duodenal ulcers! gastric adenoma! and gastric B0cell

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l"mphoma, 6ingle antibiotic therap" for H. pyloriinfection is not eective foreradication and ma" result in bacterial resistance that is more dicult to treat thanthe initial infection,

b, 0hat 1ould you recommend for the treatment of his condition# common therapeutic approach would be to use a proton pump inhibitor

plus clarithrom"cin plus eithermetronida1ole or amoicillin for )4 da"s, #nothercommon approach would be to use a proton pump inhibitorplus metronida1ole plusbismuth plustetrac"cline,

c, 0hat is the most common prolem oser5ed 1ith yourrecommended regimen

The most common problem observed with these therapeutic regimens is poor patientcompliance due to the number of medications that must be taken each da" and tomedication0related side eects,

Table @*0) Therap" of 2elicobacter p"lori -nfection

Triple therapy H14

days: Proton pump inhibitor

A clarithrom"cin mg

plus metronida1ole mg

oramoicillin ) g twice a da"

3tetrac"cline mg can be

substituted

for amoicillin or metronida1ole

uadruple therapy H14days: Proton pump inhibitor

twice a da"

A metronida1ole mg three

times dail"

plusbismuth subsalic"late *

mg A tetrac"cline mg four

times dail"

2* receptor antagonist twice ada" plus bismuth subsalic"late

* mg A metronida1ole *

mg A tetrac"cline mg four

times dail"

DOSAGES:

Proton pump inhibitors. 2* receptor antagonists.

mepra1ole. * mg Cimetidine. 4 mg 7ansopra1ole. @ mg ;amotidine. * mg

%abepra1ole. * mg 5i1atidine. ) mg

Pantopra1ole. 4 mg %anitidine. ) mg

+somepra1ole. 4 mg

CA*& 32.3# F40"ear0old man is referred because of stomach pain, 2e has beendiagnosed with osteoarthritis and has been taking a C:0) inhibitor for thepast @ months, Workup shows that he has a duodenal ulcer that "ou suspectis a result of his 56#-( use,

a, escrie the pathogenesis of "*A!.induced ulcers8

56#-(s diminish prostaglandin formation b" inhibiting c"cloo"genase, This eectcan result in enhanced gastric acid secretion 3prostaglandins ma" lower gastric acidsecretion, -n addition! prostaglandins stimulate gastric mucin production thatprovides a c"toprotective eect to the gastric mucosa which is diminished b" 56#-(s,

b, 0hat are your therapeutic options

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ne option is to change this patient to an 56#-( that is a selective inhibitor of C:0*!although this ma" not completel" eliminate the risk of ulcer formation, #notheroption is to tr" misoprostol although it has numerous gastrointestinal side eects and40times0dail" dosing is inconvenient, ;inall"! 56#-(0induced ulcers can be managedwith acid suppression using either an 2* receptor antagonist or proton pump inhibitor,Proton pump inhibitors can eectivel" heal active ulcers and prevent recurrence in

the setting of continued 56#-( administration,

9& C$"C&P#*

• Proton pump inhibitors are superior to 2* receptor antagonists for acid suppression in

patients with G+%( and peptic ulcers,

• Tolerance to the acid0suppressing eects of the 2* receptor antagonists is commonl"observed and limits their continuous use,

• H. pylori is eectivel" eradicated with a combination of acid0suppressing drugs and

multiple antibiotics administered for ) to )4 da"s,

• 56#-(0induced ulcers can be eectivel" treated with a proton pump inhibitor even

during continued 56#-( administration,

*U++AR . (%$G6 $6+( T T%+#T G#6T%-C #C-(-T=! P+PT-C $7C+%6! #5( G#6T%+6P2#G+#7 %+;7$:(-6+#6+

#$;!C!#!&*

C%A** A"*U'C%A**&*

"A+&* C%!"!CA% U*&* C$++$"U"!


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#$;!C!#!&*

C%A** A"*U'C%A**&*

"A+&* C%!"!CA% U*&* C$++$"U"!

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Chapter 32 Supplemental