Peptic Ulcer Disease Anatomy and Physiology of GI
![Peptic Ulcer Disease Peptic Ulcer Disease](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-1.jpg)
![Anatomy and Physiology of GI Tract Anatomy and Physiology of GI Tract](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-2.jpg)
![Definition: � Peptic ulcer disease (PUD) = Mucosal break/defect in the gastrointestinal tract (gastric Definition: � Peptic ulcer disease (PUD) = Mucosal break/defect in the gastrointestinal tract (gastric](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-3.jpg)
![Sites of Peptic Ulcer �Duodenum: First portion ( few cms from the pyloric ring). Sites of Peptic Ulcer �Duodenum: First portion ( few cms from the pyloric ring).](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-4.jpg)
![Peptic Ulcer Disease Peptic Ulcer Disease](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-5.jpg)
![Classification ₪ Stomach (called gastric ulcer) ₪ Duodenum (called duodenal ulcer) ₪ Oesophagus (called Classification ₪ Stomach (called gastric ulcer) ₪ Duodenum (called duodenal ulcer) ₪ Oesophagus (called](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-6.jpg)
![Risk Factors �Lifestyle � Smoking � Acidic drinks � Medications �Gender � Duodenal: are Risk Factors �Lifestyle � Smoking � Acidic drinks � Medications �Gender � Duodenal: are](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-7.jpg)
![ROLE OF H. Pylori INFECTION H. pylori infection is present in almost all patients ROLE OF H. Pylori INFECTION H. pylori infection is present in almost all patients](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-8.jpg)
![Mechanism of H pylori �H pylori secretes urease (generates ammonia), protease (breaks down glycoprotein Mechanism of H pylori �H pylori secretes urease (generates ammonia), protease (breaks down glycoprotein](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-9.jpg)
![Pathophysiology PUD is a result of acid/pepsin production imbalance with protective mechanisms such as Pathophysiology PUD is a result of acid/pepsin production imbalance with protective mechanisms such as](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-10.jpg)
![Differentiating between H. pylori and NSAID-induced ulcer Ulcers associated with H. pylori Ulcers associated Differentiating between H. pylori and NSAID-induced ulcer Ulcers associated with H. pylori Ulcers associated](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-11.jpg)
![Gastric Ulcers �Common in late middle age �incidence increases with age �Male to female Gastric Ulcers �Common in late middle age �incidence increases with age �Male to female](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-12.jpg)
![Duodenal Ulcers �duodenal sites are 4 x as common as gastric sites �most common Duodenal Ulcers �duodenal sites are 4 x as common as gastric sites �most common](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-13.jpg)
![Lab Studies to Evaluate PUD �CBC - evaluate acute/chronic blood loss �H. Pylori - Lab Studies to Evaluate PUD �CBC - evaluate acute/chronic blood loss �H. Pylori -](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-14.jpg)
![Diagnosis of H pyloric �Breath Tests & Stool antigen tests - Urea Breath Test Diagnosis of H pyloric �Breath Tests & Stool antigen tests - Urea Breath Test](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-15.jpg)
![PUD Diagnosis Initial Differential Diagnosis More Common: �Gastroesophageal reflux disease �Nonulcer dyspepsia/ Gastritis �Ulcer PUD Diagnosis Initial Differential Diagnosis More Common: �Gastroesophageal reflux disease �Nonulcer dyspepsia/ Gastritis �Ulcer](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-16.jpg)
![Signs and Symptoms of PUD �Epigastric pain is most common symptom �Pain described as Signs and Symptoms of PUD �Epigastric pain is most common symptom �Pain described as](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-17.jpg)
![Complications �Perforation & Penetration—into pancreas, liver and retroperitoneal space �Peritonitis �Bowel obstruction, Gastric outflow Complications �Perforation & Penetration—into pancreas, liver and retroperitoneal space �Peritonitis �Bowel obstruction, Gastric outflow](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-18.jpg)
![Prevention �Consider prophylactic therapy for the following patients: �Pts with NSAID-induced ulcers who require Prevention �Consider prophylactic therapy for the following patients: �Pts with NSAID-induced ulcers who require](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-19.jpg)
![�Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric �Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-20.jpg)
![Treatment Goals �Relieve symptoms �Healing of ulcer �Eliminating cause of ulcer • lowering the Treatment Goals �Relieve symptoms �Healing of ulcer �Eliminating cause of ulcer • lowering the](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-21.jpg)
![Classification 1. Acid Neutralizing agents: (ANTACIDS) • Systemic: Sodium Bicarbonate and Sod. Citrate • Classification 1. Acid Neutralizing agents: (ANTACIDS) • Systemic: Sodium Bicarbonate and Sod. Citrate •](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-22.jpg)
![2. Reduction in Gastric acid secretion: � H 2 antihistamines: Cimetidine, Ranitidine, Famotidine, Nizatidine 2. Reduction in Gastric acid secretion: � H 2 antihistamines: Cimetidine, Ranitidine, Famotidine, Nizatidine](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-23.jpg)
![3. 4. Ulcer protectives: Sucralfate, Colloidal Bismuth sudcitrate Anti-H. pylori Drugs: Amoxicillin, Clarithromycin, metronidazole, 3. 4. Ulcer protectives: Sucralfate, Colloidal Bismuth sudcitrate Anti-H. pylori Drugs: Amoxicillin, Clarithromycin, metronidazole,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-24.jpg)
![PGE 2 + Histamine + ACh M 3 Ranitidine Gastrin _ Proglumide _ Misoprostol PGE 2 + Histamine + ACh M 3 Ranitidine Gastrin _ Proglumide _ Misoprostol](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-25.jpg)
![Antacids �Present day antacids : � Aluminium Hydroxide (1 -2. 5 m. Eq/g) � Antacids �Present day antacids : � Aluminium Hydroxide (1 -2. 5 m. Eq/g) �](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-26.jpg)
![�Side effects : �Aluminium antacids – constipation (As they relax gastric smooth muscle & �Side effects : �Aluminium antacids – constipation (As they relax gastric smooth muscle &](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-27.jpg)
![H 2 Antagonists �Cimetidine, Ranitidine, Famotidine, Roxatidine, Nizatidine and �MOA: �Reversible competitive inhibitors of H 2 Antagonists �Cimetidine, Ranitidine, Famotidine, Roxatidine, Nizatidine and �MOA: �Reversible competitive inhibitors of](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-28.jpg)
![�Kinetics: �All drugs are absorbed orally adequately �Bioavailability upto 80 % �Absorption is not �Kinetics: �All drugs are absorbed orally adequately �Bioavailability upto 80 % �Absorption is not](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-29.jpg)
![ADRs �Extremely safe drugs and well tolerated �Main ADRs are related to Cimetidine: �Antiandrogenic ADRs �Extremely safe drugs and well tolerated �Main ADRs are related to Cimetidine: �Antiandrogenic](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-30.jpg)
![�Others: �Headache, dizziness, bowel upset, dry mouth �Bolus IV – release histamine – bradycardia, �Others: �Headache, dizziness, bowel upset, dry mouth �Bolus IV – release histamine – bradycardia,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-31.jpg)
![Comparison of H 2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Bioavailability 80 50 40 >90 Comparison of H 2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Bioavailability 80 50 40 >90](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-32.jpg)
![Uses Promote the healing of gastric and duodenal ulcers � Duodenal ulcer – 70 Uses Promote the healing of gastric and duodenal ulcers � Duodenal ulcer – 70](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-33.jpg)
![H 2 blockers Tablets in Peptic ulcer Cimetidine 800 mg bedtime /400 mg. Bd H 2 blockers Tablets in Peptic ulcer Cimetidine 800 mg bedtime /400 mg. Bd](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-34.jpg)
![Proton Pump Inhibitors �Most effective drugs in antiulcer therapy �Prodrugs requiring activation in acid Proton Pump Inhibitors �Most effective drugs in antiulcer therapy �Prodrugs requiring activation in acid](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-35.jpg)
![Omeprazole - MOA �Substituted Benzimidazole derivative �Its a Prodrug �Diffuses into G. canaliculi = Omeprazole - MOA �Substituted Benzimidazole derivative �Its a Prodrug �Diffuses into G. canaliculi =](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-36.jpg)
![](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-37.jpg)
![Pharmacokinetics - PPI • Oral forms are prepared as acid resistant formulations that release Pharmacokinetics - PPI • Oral forms are prepared as acid resistant formulations that release](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-38.jpg)
![• Given on an empty stomach because food affects absorption • They should • Given on an empty stomach because food affects absorption • They should](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-39.jpg)
![Adverse Effects • The most common are GIT troubles in the form of nausea, Adverse Effects • The most common are GIT troubles in the form of nausea,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-40.jpg)
![Drug Interaction: Inhibits metabolism of Warfarin, Diazepam Therapeutic uses: � � � � Gastroesophageal Drug Interaction: Inhibits metabolism of Warfarin, Diazepam Therapeutic uses: � � � � Gastroesophageal](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-41.jpg)
![PPI – Dosage schedule �Omeprazole �Lansoprazole �Pantoprazole �Rabeprazole �Esomeprazole 20 mg o. d. 30 PPI – Dosage schedule �Omeprazole �Lansoprazole �Pantoprazole �Rabeprazole �Esomeprazole 20 mg o. d. 30](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-42.jpg)
![Muscarinic antagonists Atropine: � Block the M 1 class receptors � Reduce acid production Muscarinic antagonists Atropine: � Block the M 1 class receptors � Reduce acid production](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-43.jpg)
![Prostaglandin analogues �Inhibit gastric acid secretion �Exhibit ‘cytoprotective’ activity �Enhance local production of mucus Prostaglandin analogues �Inhibit gastric acid secretion �Exhibit ‘cytoprotective’ activity �Enhance local production of mucus](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-44.jpg)
![](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-45.jpg)
![Prostaglandin analogues - Misoprostol Actions: Inhibit histamine-stimulated gastric acid secretion Stimulation of mucin and Prostaglandin analogues - Misoprostol Actions: Inhibit histamine-stimulated gastric acid secretion Stimulation of mucin and](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-46.jpg)
![Misoprostol � Doses: 200 mcg 4 times a day (Misoprost) � ADRs: � Diarrhoea Misoprostol � Doses: 200 mcg 4 times a day (Misoprost) � ADRs: � Diarrhoea](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-47.jpg)
![Omeprazole Amoxicillin Clarithromycin Metronidazole Eradication of H. pylori Omeprazole Amoxicillin Clarithromycin Metronidazole Eradication of H. pylori](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-48.jpg)
![Triple Therapy The BEST among all the Triple therapy regimen is: Omeprazole / Lansoprazole Triple Therapy The BEST among all the Triple therapy regimen is: Omeprazole / Lansoprazole](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-49.jpg)
![Triple Therapy – cont … Some other Triple Therapy Regimens are Bismuth subsalicylate – Triple Therapy – cont … Some other Triple Therapy Regimens are Bismuth subsalicylate –](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-50.jpg)
![Bismuth subsalicylate Pharmacological actions: • Undergoes rapid dissolution in the stomach into bismuth and Bismuth subsalicylate Pharmacological actions: • Undergoes rapid dissolution in the stomach into bismuth and](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-51.jpg)
![Surgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Other modes Of treatment Acupuncture Chiropractic Surgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Other modes Of treatment Acupuncture Chiropractic](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-52.jpg)
![Use of Olive Oil Don't smoke Limit or avoid alcohol Avoid nonsteroidal anti-inflammatory drugs Use of Olive Oil Don't smoke Limit or avoid alcohol Avoid nonsteroidal anti-inflammatory drugs](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-53.jpg)
![H 2 Receptor Antagonists THANK YOU - in stomach at all stages decreases formation H 2 Receptor Antagonists THANK YOU - in stomach at all stages decreases formation](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-54.jpg)
- Slides: 54
![Peptic Ulcer Disease Peptic Ulcer Disease](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-1.jpg)
Peptic Ulcer Disease
![Anatomy and Physiology of GI Tract Anatomy and Physiology of GI Tract](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-2.jpg)
Anatomy and Physiology of GI Tract
![Definition Peptic ulcer disease PUD Mucosal breakdefect in the gastrointestinal tract gastric Definition: � Peptic ulcer disease (PUD) = Mucosal break/defect in the gastrointestinal tract (gastric](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-3.jpg)
Definition: � Peptic ulcer disease (PUD) = Mucosal break/defect in the gastrointestinal tract (gastric or duodenal) exposed to acid and pepsin secretion �Gastritis is the precursor to PUD and it is clinically difficult to differentiate the two
![Sites of Peptic Ulcer Duodenum First portion few cms from the pyloric ring Sites of Peptic Ulcer �Duodenum: First portion ( few cms from the pyloric ring).](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-4.jpg)
Sites of Peptic Ulcer �Duodenum: First portion ( few cms from the pyloric ring). Anterior wall is more often affected. �Stomach: Usually antrum. Lesser curvature (common). Anterior and posterior wall and greater curvature (less common). �Lower esophagus �In the margins of a gastroenterostomy (stomal ulcer) �In the duodenum, stomach or jejunum of patients with Zollinger. Ellison syndrome.
![Peptic Ulcer Disease Peptic Ulcer Disease](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-5.jpg)
Peptic Ulcer Disease
![Classification Stomach called gastric ulcer Duodenum called duodenal ulcer Oesophagus called Classification ₪ Stomach (called gastric ulcer) ₪ Duodenum (called duodenal ulcer) ₪ Oesophagus (called](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-6.jpg)
Classification ₪ Stomach (called gastric ulcer) ₪ Duodenum (called duodenal ulcer) ₪ Oesophagus (called Oesophageal ulcer) ₪ Types of peptic ulcers: ₪ Type I: Ulcer along the lesser curve of stomach ₪ Type II: Two ulcers present - one gastric, one duodenal ₪ Type III: Prepyloric ulcer ₪ Type IV: Proximal gastroesophageal ulcer ₪ Type V: Anywhere
![Risk Factors Lifestyle Smoking Acidic drinks Medications Gender Duodenal are Risk Factors �Lifestyle � Smoking � Acidic drinks � Medications �Gender � Duodenal: are](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-7.jpg)
Risk Factors �Lifestyle � Smoking � Acidic drinks � Medications �Gender � Duodenal: are increasing in older women �Genetic factors � More likely if family member �H. Pylori infection � 90% have this bacterium � Passed from person to person (fecal-oral route or oral-oral route) �Age � Duodenal 30 -50 � Gastric over 60 has Hx �Other factors: stress can worsen but not the cause
![ROLE OF H Pylori INFECTION H pylori infection is present in almost all patients ROLE OF H. Pylori INFECTION H. pylori infection is present in almost all patients](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-8.jpg)
ROLE OF H. Pylori INFECTION H. pylori infection is present in almost all patients with duodenal ulcers and 70% cases with gastric ulcers. Duodenal ulcers - Usually associated with gastritis confined to the antrum. Gastric ulcers - Usually associated with pangastritis (inflammation of the entire stomach).
![Mechanism of H pylori H pylori secretes urease generates ammonia protease breaks down glycoprotein Mechanism of H pylori �H pylori secretes urease (generates ammonia), protease (breaks down glycoprotein](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-9.jpg)
Mechanism of H pylori �H pylori secretes urease (generates ammonia), protease (breaks down glycoprotein in gastric mucus) �- breakdown of mucosal defense �Damage of the protective mucosal layer. The epithelial cells are exposed to the damaging effect of acid-peptic digestion. �Inflammation of the gastric mucosa. �Chronically inflamed mucosa more susceptible to acid- peptic injury and prone to peptic ulceration. � Ulcers occur at sites of chronic inflammation Eg - Antrum
![Pathophysiology PUD is a result of acidpepsin production imbalance with protective mechanisms such as Pathophysiology PUD is a result of acid/pepsin production imbalance with protective mechanisms such as](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-10.jpg)
Pathophysiology PUD is a result of acid/pepsin production imbalance with protective mechanisms such as mucous production
![Differentiating between H pylori and NSAIDinduced ulcer Ulcers associated with H pylori Ulcers associated Differentiating between H. pylori and NSAID-induced ulcer Ulcers associated with H. pylori Ulcers associated](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-11.jpg)
Differentiating between H. pylori and NSAID-induced ulcer Ulcers associated with H. pylori Ulcers associated with NSAIDs �more often in duodenum �often superficial �less severe GI bleeding �more often in stomach �often deep �more severe GI bleeding �sometimes asymptomatic
![Gastric Ulcers Common in late middle age incidence increases with age Male to female Gastric Ulcers �Common in late middle age �incidence increases with age �Male to female](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-12.jpg)
Gastric Ulcers �Common in late middle age �incidence increases with age �Male to female ratio— 2: 1 �More common in patients with blood group A �Use of NSAIDs - associated with a three- to fourfold increase in risk of gastric ulcer �Less related to H. pylori than duodenal ulcers – about 80% � 10 - 20% of patients with a gastric ulcer have a concomitant duodenal ulcer
![Duodenal Ulcers duodenal sites are 4 x as common as gastric sites most common Duodenal Ulcers �duodenal sites are 4 x as common as gastric sites �most common](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-13.jpg)
Duodenal Ulcers �duodenal sites are 4 x as common as gastric sites �most common in middle age �peak 30 -50 years �Male to female ratio— 4: 1 �Genetic link: 3 x more common in 1 st degree relatives �more common in patients with blood group O �associated with increased serum pepsinogen �H. pylori infection common �up to 95% �smoking is twice as common
![Lab Studies to Evaluate PUD CBC evaluate acutechronic blood loss H Pylori Lab Studies to Evaluate PUD �CBC - evaluate acute/chronic blood loss �H. Pylori -](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-14.jpg)
Lab Studies to Evaluate PUD �CBC - evaluate acute/chronic blood loss �H. Pylori - Serologic antibody test for HP – does not active HP infection - Fecal antigen tests for active HP - Urea breath tests for active HP determine if
![Diagnosis of H pyloric Breath Tests Stool antigen tests Urea Breath Test Diagnosis of H pyloric �Breath Tests & Stool antigen tests - Urea Breath Test](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-15.jpg)
Diagnosis of H pyloric �Breath Tests & Stool antigen tests - Urea Breath Test ( 95 -100% specificity) -In office test (breath) �Urea Blood test – Less Specific �Endoscopy – culture of organism to determine antibiotic therapy �Serologic test – not reliable (persisting antibiodies)
![PUD Diagnosis Initial Differential Diagnosis More Common Gastroesophageal reflux disease Nonulcer dyspepsia Gastritis Ulcer PUD Diagnosis Initial Differential Diagnosis More Common: �Gastroesophageal reflux disease �Nonulcer dyspepsia/ Gastritis �Ulcer](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-16.jpg)
PUD Diagnosis Initial Differential Diagnosis More Common: �Gastroesophageal reflux disease �Nonulcer dyspepsia/ Gastritis �Ulcer disease �Gastroenteritis �Biliary colic or cholecystitis �Pancreatitis �Irritable bowel disease
![Signs and Symptoms of PUD Epigastric pain is most common symptom Pain described as Signs and Symptoms of PUD �Epigastric pain is most common symptom �Pain described as](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-17.jpg)
Signs and Symptoms of PUD �Epigastric pain is most common symptom �Pain described as gnawing/ burning / annoying �May radiate to the back (consider penetration) �Pain occurs when stomach is empty �Relieved by food, antacids (duodenal), Dyspepsia including belching/ bloating �Hematemesis or melena with GI bleeding �NSAID-induced gastritis or ulcers are frequently “silent”
![Complications Perforation Penetrationinto pancreas liver and retroperitoneal space Peritonitis Bowel obstruction Gastric outflow Complications �Perforation & Penetration—into pancreas, liver and retroperitoneal space �Peritonitis �Bowel obstruction, Gastric outflow](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-18.jpg)
Complications �Perforation & Penetration—into pancreas, liver and retroperitoneal space �Peritonitis �Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis �Bleeding--occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths. �Gastric CA
![Prevention Consider prophylactic therapy for the following patients Pts with NSAIDinduced ulcers who require Prevention �Consider prophylactic therapy for the following patients: �Pts with NSAID-induced ulcers who require](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-19.jpg)
Prevention �Consider prophylactic therapy for the following patients: �Pts with NSAID-induced ulcers who require daily NSAID therapy �Pts older than 60 years �Pts with a history of PUD or a complication such as GI bleeding �Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses
![Prophylactic regimens that have been shown to dramatically reduce the risk of NSAIDinduced gastric �Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-20.jpg)
�Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor. �Misoprostol --- 100 -200 mcg PO 4 times per day �Omeprazole ---- 20 -40 mg PO every day �Lansoprazole ------- 15 -30 mg PO every day
![Treatment Goals Relieve symptoms Healing of ulcer Eliminating cause of ulcer lowering the Treatment Goals �Relieve symptoms �Healing of ulcer �Eliminating cause of ulcer • lowering the](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-21.jpg)
Treatment Goals �Relieve symptoms �Healing of ulcer �Eliminating cause of ulcer • lowering the amount of acid that stomach makes, • neutralizing the acid • protecting the injured area so it can heal • It's also very important to stop smoking and drinking alcohol • Prevent complications (bleeding, perforation, penetration, obstruction) • Minimize recurrences • Reduce financial costs
![Classification 1 Acid Neutralizing agents ANTACIDS Systemic Sodium Bicarbonate and Sod Citrate Classification 1. Acid Neutralizing agents: (ANTACIDS) • Systemic: Sodium Bicarbonate and Sod. Citrate •](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-22.jpg)
Classification 1. Acid Neutralizing agents: (ANTACIDS) • Systemic: Sodium Bicarbonate and Sod. Citrate • Nonsystemic: Magnesium hydroxide, Mag. Treisilicate, Aluminium hydroxide gel, Magaldrate and calcium carbonate
![2 Reduction in Gastric acid secretion H 2 antihistamines Cimetidine Ranitidine Famotidine Nizatidine 2. Reduction in Gastric acid secretion: � H 2 antihistamines: Cimetidine, Ranitidine, Famotidine, Nizatidine](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-23.jpg)
2. Reduction in Gastric acid secretion: � H 2 antihistamines: Cimetidine, Ranitidine, Famotidine, Nizatidine and Roxatidine � Proton pump inhibitors: Omeprazole, Lansoprazole Pantoprazole, Rabeprazole and Esomeprazole � Anticholinergics: Pirenzepine, Propantheline and Oxyphenonium � Prostaglandin analogue: Misoprostol
![3 4 Ulcer protectives Sucralfate Colloidal Bismuth sudcitrate AntiH pylori Drugs Amoxicillin Clarithromycin metronidazole 3. 4. Ulcer protectives: Sucralfate, Colloidal Bismuth sudcitrate Anti-H. pylori Drugs: Amoxicillin, Clarithromycin, metronidazole,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-24.jpg)
3. 4. Ulcer protectives: Sucralfate, Colloidal Bismuth sudcitrate Anti-H. pylori Drugs: Amoxicillin, Clarithromycin, metronidazole, tinidazole and tetracycline
![PGE 2 Histamine ACh M 3 Ranitidine Gastrin Proglumide Misoprostol PGE 2 + Histamine + ACh M 3 Ranitidine Gastrin _ Proglumide _ Misoprostol](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-25.jpg)
PGE 2 + Histamine + ACh M 3 Ranitidine Gastrin _ Proglumide _ Misoprostol _ PGE receptor Adenyl cyclase ATP Ca++ + + H 2 + c. AMP + Gastrin receptor Ca++ + Protein Kinase (Activated) K+ + H+ K _ Omeprazole Proton pump Gastric acid Parietal cell Lumen of stomach _ Antacid
![Antacids Present day antacids Aluminium Hydroxide 1 2 5 m Eqg Antacids �Present day antacids : � Aluminium Hydroxide (1 -2. 5 m. Eq/g) �](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-26.jpg)
Antacids �Present day antacids : � Aluminium Hydroxide (1 -2. 5 m. Eq/g) � Magnesium Hydroxide ( 30 m. Eq) – milk of magnesia � Magnesium trisilicate ( 1 m. Eq/g) �Duration of action : 30 min when taken in empty stomach and 2 hrs when taken after a meal
![Side effects Aluminium antacids constipation As they relax gastric smooth muscle �Side effects : �Aluminium antacids – constipation (As they relax gastric smooth muscle &](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-27.jpg)
�Side effects : �Aluminium antacids – constipation (As they relax gastric smooth muscle & delay gastric emptying) – also hypophosphatemia and osteomalcia �Mg 2+ antacids – Osmotic diarrhoea �In renal failure Al 3+ antacid – Aluminium toxicity & Encephalopathy (Magaldrate – hydrated hydroxy magnesium aluminate)
![H 2 Antagonists Cimetidine Ranitidine Famotidine Roxatidine Nizatidine and MOA Reversible competitive inhibitors of H 2 Antagonists �Cimetidine, Ranitidine, Famotidine, Roxatidine, Nizatidine and �MOA: �Reversible competitive inhibitors of](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-28.jpg)
H 2 Antagonists �Cimetidine, Ranitidine, Famotidine, Roxatidine, Nizatidine and �MOA: �Reversible competitive inhibitors of H 2 receptor �Highly selective, no action on H 1 or H 3 receptors �All phases of gastric acid secretion �Very effective in inhibiting nocturnal acid secretion (as it depends largely on Histamine ) �Modest impact on meal stimulated acid secretion (as it depends on gastrin, acetylcholine and histamine) �Volume of pepsin content and IF are also reduced �Volume reduced by 60 – 70% - anti ulcerogenic effect �No effect on motility
![Kinetics All drugs are absorbed orally adequately Bioavailability upto 80 Absorption is not �Kinetics: �All drugs are absorbed orally adequately �Bioavailability upto 80 % �Absorption is not](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-29.jpg)
�Kinetics: �All drugs are absorbed orally adequately �Bioavailability upto 80 % �Absorption is not interfered by presence of food �Can cross placental barrier and reaches milk �Poor CNS penetration � 2/3 rd of the drugs are excreted unchanged in bile and urine �Preparations: available as tablets, injections
![ADRs Extremely safe drugs and well tolerated Main ADRs are related to Cimetidine Antiandrogenic ADRs �Extremely safe drugs and well tolerated �Main ADRs are related to Cimetidine: �Antiandrogenic](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-30.jpg)
ADRs �Extremely safe drugs and well tolerated �Main ADRs are related to Cimetidine: �Antiandrogenic effects �Increases prolactin secretion and inhibits degradation of estradiol by liver �Cytochrome P 450 inhibition – theophylline, metronidazole, phenytoin, imipramine etc. �Antacids
![Others Headache dizziness bowel upset dry mouth Bolus IV release histamine bradycardia �Others: �Headache, dizziness, bowel upset, dry mouth �Bolus IV – release histamine – bradycardia,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-31.jpg)
�Others: �Headache, dizziness, bowel upset, dry mouth �Bolus IV – release histamine – bradycardia, arrhythmia, cardiac arrest �Elderly - precaution
![Comparison of H 2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Bioavailability 80 50 40 90 Comparison of H 2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Bioavailability 80 50 40 >90](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-32.jpg)
Comparison of H 2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Bioavailability 80 50 40 >90 Relative Potency 1 5 -10 32 5 -10 Half life (hrs) 1. 5 - 2. 3 1. 6 - 2. 4 2. 5 - 4 1. 1 -1. 6 Duration of 6 8 12 8 action (hrs) Inhibition of 1 0. 1 0 CYP 450 Dose mg (bd) 400 150 20 150 Antiandrogenic effect, prolactin secretion and gynocomastia
![Uses Promote the healing of gastric and duodenal ulcers Duodenal ulcer 70 Uses Promote the healing of gastric and duodenal ulcers � Duodenal ulcer – 70](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-33.jpg)
Uses Promote the healing of gastric and duodenal ulcers � Duodenal ulcer – 70 to 90% � Gastric Ulcer – 50 to 75% (NSAID ulcers)) � Stress ulcer and gastritis � GERD � Zollinger-Ellison syndrome � Prophylaxis of aspiration pneumonia � Urticaria Doses: • 300 mg/40 mg/150 mg at bed time of R, F, Rox respectively for healing • Maintenance: 150/20/150 mg BD of R, F, Rox
![H 2 blockers Tablets in Peptic ulcer Cimetidine 800 mg bedtime 400 mg Bd H 2 blockers Tablets in Peptic ulcer Cimetidine 800 mg bedtime /400 mg. Bd](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-34.jpg)
H 2 blockers Tablets in Peptic ulcer Cimetidine 800 mg bedtime /400 mg. Bd 400 mg bedtime Ranitidine 300 mg bedtime/150 mg BD 150 mg bedtime Famotidine 40 mg bedtime 20 mg bedtime Roxatidine 150 mg bedtime 75 mg bedtime
![Proton Pump Inhibitors Most effective drugs in antiulcer therapy Prodrugs requiring activation in acid Proton Pump Inhibitors �Most effective drugs in antiulcer therapy �Prodrugs requiring activation in acid](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-35.jpg)
Proton Pump Inhibitors �Most effective drugs in antiulcer therapy �Prodrugs requiring activation in acid environment �Block enzymes responsible for secreting HCl - binds irreversibly to H+K+ATPase �Prototype: Omeprazole (Prilosec) �Examples: �Lansoprazole �Pantoprazole �Rabeprazole �Esomeprazole
![Omeprazole MOA Substituted Benzimidazole derivative Its a Prodrug Diffuses into G canaliculi Omeprazole - MOA �Substituted Benzimidazole derivative �Its a Prodrug �Diffuses into G. canaliculi =](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-36.jpg)
Omeprazole - MOA �Substituted Benzimidazole derivative �Its a Prodrug �Diffuses into G. canaliculi = accumulation p. H < 5 (proton catalyzed )= tetracyclic sulfenamide + sulphenic acid �Covalent binding with sulfhydryl cysteines of H⁺K⁺ ATPase �Irreversible inactivation of the pump molecule (The charged forms cannot diffuse back across the canaliculi) �Acid suppressants regardless of stimulating factors �Also inhibits gastric mucosal carbonic anhydrase
![](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-37.jpg)
![Pharmacokinetics PPI Oral forms are prepared as acid resistant formulations that release Pharmacokinetics - PPI • Oral forms are prepared as acid resistant formulations that release](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-38.jpg)
Pharmacokinetics - PPI • Oral forms are prepared as acid resistant formulations that release the drug in the intestine (because they are degraded in acid media) • After absorption, they are distributed by blood to parietal cell canaliculi • They irreversibly inactivate the proton pump molecule – but half life is very short and only 1 -2 Hrs • Still action persists for 24 Hrs to 48 hrs after a single dose – irreversible inhibition of PPI and new PP synthesis takes time (24 to 48 hour suppression of acid secretion, despite the much shorter plasma half-lives of the parent compounds) • Platue state is attained after 4 -5 days of dosing • Action lasts for 4 -5 days even after stoppage of the drug
![Given on an empty stomach because food affects absorption They should • Given on an empty stomach because food affects absorption • They should](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-39.jpg)
• Given on an empty stomach because food affects absorption • They should be given 30 minutes to 1 hour before food intake because an acidic p. H in the parietal cell acid canaliculi is required for drug activation, and food stimulates acid production • Concomitant use of other antisecretory drugs - H 2 receptor antagonists – reduces action • Highly protein bound and rapidly Metabolized by the liver by CYP 2 C 19 and CYP 3 A 4 – dose reduction necessary in severe hepatic failure • Excreted in Kidneys minimally (no dose reduction needed in renal failure and elderly)
![Adverse Effects The most common are GIT troubles in the form of nausea Adverse Effects • The most common are GIT troubles in the form of nausea,](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-40.jpg)
Adverse Effects • The most common are GIT troubles in the form of nausea, abdominal pain, constipation, flatulence, and diarrhea • Subacute myopathy, arthralgias, headaches, and skin rashes • Prolonged use: • Gynaecomastia, erectile dysfunction • Leucopenia and hepatic dysfunction • Vitamin B 12 deficiency • Hypergastrinemia which may predispose to rebound hypersecretion of gastric acid upon discontinuation of therapy and may promote the growth of gastrointestinal tumors (carcinoid tumors )
![Drug Interaction Inhibits metabolism of Warfarin Diazepam Therapeutic uses Gastroesophageal Drug Interaction: Inhibits metabolism of Warfarin, Diazepam Therapeutic uses: � � � � Gastroesophageal](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-41.jpg)
Drug Interaction: Inhibits metabolism of Warfarin, Diazepam Therapeutic uses: � � � � Gastroesophageal reflux disease (GERD) Peptic Ulcer - Gastric and duodenal ulcers Bleeding peptic Ulcer Zollinger ellison Syndrome Prevention of recurrence of nonsteroidal antiinflammatory drug (NSAID) - associated gastric ulcers in patients who continue NSAID use. Reducing the risk of duodenal ulcer recurrence associated with H. pylori infections Aspiration Pneumonia
![PPI Dosage schedule Omeprazole Lansoprazole Pantoprazole Rabeprazole Esomeprazole 20 mg o d 30 PPI – Dosage schedule �Omeprazole �Lansoprazole �Pantoprazole �Rabeprazole �Esomeprazole 20 mg o. d. 30](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-42.jpg)
PPI – Dosage schedule �Omeprazole �Lansoprazole �Pantoprazole �Rabeprazole �Esomeprazole 20 mg o. d. 30 mg o. d. 40 mg o. d. 20 - 40 mg o. d.
![Muscarinic antagonists Atropine Block the M 1 class receptors Reduce acid production Muscarinic antagonists Atropine: � Block the M 1 class receptors � Reduce acid production](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-43.jpg)
Muscarinic antagonists Atropine: � Block the M 1 class receptors � Reduce acid production � Abolish gastrointestinal spasm Pirenzepine and Telenzepine Mechanism of action: • Reduce meal stimulated HCl secretion by reversible blockade of muscarinic (M 1) receptors on the cell bodies of the intramural cholinergic ganglia (receptors on parietal cells are M 3). � Unpopular as a first choice because of high incidence of anticholinergic side effects (dry mouth and blurred vision)
![Prostaglandin analogues Inhibit gastric acid secretion Exhibit cytoprotective activity Enhance local production of mucus Prostaglandin analogues �Inhibit gastric acid secretion �Exhibit ‘cytoprotective’ activity �Enhance local production of mucus](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-44.jpg)
Prostaglandin analogues �Inhibit gastric acid secretion �Exhibit ‘cytoprotective’ activity �Enhance local production of mucus or bicarbonate �Promote local cell regeneration �Help to maintain mucosal blood
![](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-45.jpg)
![Prostaglandin analogues Misoprostol Actions Inhibit histaminestimulated gastric acid secretion Stimulation of mucin and Prostaglandin analogues - Misoprostol Actions: Inhibit histamine-stimulated gastric acid secretion Stimulation of mucin and](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-46.jpg)
Prostaglandin analogues - Misoprostol Actions: Inhibit histamine-stimulated gastric acid secretion Stimulation of mucin and bicarbonate secretion Increase mucosal blood flow (Reinforcing of mucous layer buffered by HCO 3 secretion from epithelial cells) Therapeutic uses: Prevent ion of NSAID-induced mucosal injury (rarely used because it needs frequent administration – 4 times daily)
![Misoprostol Doses 200 mcg 4 times a day Misoprost ADRs Diarrhoea Misoprostol � Doses: 200 mcg 4 times a day (Misoprost) � ADRs: � Diarrhoea](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-47.jpg)
Misoprostol � Doses: 200 mcg 4 times a day (Misoprost) � ADRs: � Diarrhoea and abdominal cramps � Uterine bleeding � Abortion � Exacerbations of inflammatory bowel disease and should be avoided in patients with this disorder Contraindications: 1. Inflammatory bowel disease 2. Pregnancy (may cause abortion)
![Omeprazole Amoxicillin Clarithromycin Metronidazole Eradication of H pylori Omeprazole Amoxicillin Clarithromycin Metronidazole Eradication of H. pylori](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-48.jpg)
Omeprazole Amoxicillin Clarithromycin Metronidazole Eradication of H. pylori
![Triple Therapy The BEST among all the Triple therapy regimen is Omeprazole Lansoprazole Triple Therapy The BEST among all the Triple therapy regimen is: Omeprazole / Lansoprazole](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-49.jpg)
Triple Therapy The BEST among all the Triple therapy regimen is: Omeprazole / Lansoprazole - 20 / 30 mg bd Clarithromycin - 500 mg bd Amoxycillin / Metronidazole - 1 gm / 500 mg bd Given for 14 days followed by P. P. I for 4 – 6 weeks Short regimens for 7 – 10 days not very effective
![Triple Therapy cont Some other Triple Therapy Regimens are Bismuth subsalicylate Triple Therapy – cont … Some other Triple Therapy Regimens are Bismuth subsalicylate –](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-50.jpg)
Triple Therapy – cont … Some other Triple Therapy Regimens are Bismuth subsalicylate – 2 tab qid Metronidazole - 250 mg qid Tetracycline - 500 mg qid Ranitidine Bismuth citrate - 400 mg bd Tetracycline - 500 mg bd Clarithromycin / Metronidazole - 500 mg bd
![Bismuth subsalicylate Pharmacological actions Undergoes rapid dissolution in the stomach into bismuth and Bismuth subsalicylate Pharmacological actions: • Undergoes rapid dissolution in the stomach into bismuth and](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-51.jpg)
Bismuth subsalicylate Pharmacological actions: • Undergoes rapid dissolution in the stomach into bismuth and salicylates • Salicylates are absorbed • Bismuth coats ulcers and erosions protecting them from acid and pepsin and increases prostaglandin and bicarbonate production • Uses: • Treatment of dyspepsia and acute diarrhoea
![Surgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Other modes Of treatment Acupuncture Chiropractic Surgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Other modes Of treatment Acupuncture Chiropractic](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-52.jpg)
Surgery Vagotomy Antrectomy Pyloroplasty Tying off an artery Other modes Of treatment Acupuncture Chiropractic Homeopathy Herbs
![Use of Olive Oil Dont smoke Limit or avoid alcohol Avoid nonsteroidal antiinflammatory drugs Use of Olive Oil Don't smoke Limit or avoid alcohol Avoid nonsteroidal anti-inflammatory drugs](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-53.jpg)
Use of Olive Oil Don't smoke Limit or avoid alcohol Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) Less Coffee and Carbonated Beverages Exercise Fruits and Vegetables Stress Relief
![H 2 Receptor Antagonists THANK YOU in stomach at all stages decreases formation H 2 Receptor Antagonists THANK YOU - in stomach at all stages decreases formation](https://slidetodoc.com/presentation_image_h/2175c17751a310a530efc49f833c24b8/image-54.jpg)
H 2 Receptor Antagonists THANK YOU - in stomach at all stages decreases formation of HCl by selective blocking of H 2 receptors - therapeutic effect after 4 weeks - 60 -80% efficiency, after 8 weeks even 90%, 10 -15% resistance Ranitidine, Famotidine /more effective/, Nizatidine: /12 x daily/ - good pharmacokinetic /p. o. absorbtion, metabolism in liver/ and safety profile, good tollerance - long-term maintenance therapy after uncomplicated peptic ulcer healing and treatment of some forms of gastric dyspepsias
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