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					                                                                     Section 1 Introduction


1.1 Introduction :
Expenditure on medicines is increasing at a higher rate than general inflation, requiring
many governments to introduce cost effectiveness programme. More complex inpatient
care results from new technology, higher acuity of illness, and shorter hospital stays are
placing heavier demands on health care practitioners. These trends are reflected in the
increasing number, types, and cost of prescribed drugs


1.2 Definitions used in Economics in health care:
Pharmacoeconomics :
It can be defined as the measurement of both the costs and consequences of therapeutic
decision making . Pharmacoeconomics can assist in the planning process and help assign
priorities where , for example , medicines with a worse outcome may be available at a
lower cost and medicines with better outcome and higher cost can be compared .


The Role of Cost in Drug Decisions
If drugs are not used properly, overall drug costs increase. Consequently, health care
organizations cannot contain overall cost by simply choosing the cheapest drug for a
given indication. Since drugs differ in safety and efficacy, minimizing overall costs
requires both effectiveness and costs to be analyzed, generating a cost per outcome.


1.3 Types of Health Economic evaluations :
In economic evaluation of heath care, consequences can be expressed in monetary terms
:
       Cost –benefit analysis(CBA)
       Cost-effectiveness analysis(CEA)
       In terms of patient preference or utility analysis (cost – utility) (CUA)
In Cost benefit analysis , consequences are measured in terms of the total cost
associated with a programme where both costs and consequences are measured in



                                                                                             1
monetary terms. “Efficiency" is a determination of whether the drug is worth the resource
utilization.
In Cost effectiveness analysis , it can be described as an examination of the costs of
two or more programmes which have the same clinical outcome as measured in physical
units , “Effectiveness" is an assessment of whether the drug works under usual clinical
circumstances
In Cost- utility analysis , an alternative measurement for the consequences of a
health care intervention is the concept of utility. This method allows us to estimate the
patients preference for a particular intervention in terms of his state of well being.


1.4 Cost of Different Strategies for Treating Peptic Ulcer :

Drug Name                                   Trade Name                         Drug Cost

Histamine H2 receptor blocker :             Cimedine 400mg                     25.00 Dhs
Cimetidine                                  Cimetidine                         15.50 Dhs
Ranitidine                         Apo Ranitidine 300mg 12 tabs                39.00 Dhs
                                   Apo Ranitidine 300mg 20 tabs                39.50 Dhs
                                   Zantac 300mg 10 tabs                        81.00 Dhs
                                   Zantac 300mg 20 tabs                        87.50 Dhs
                                   Zantac Injection 5 * 21                     30.00 Dhs
                                   Zantac 75 mg                                22.00 Dhs
                                   Rantag Injection 50mg/2ml                   25.50 Dhs
                                   Histac 150                                  36.00 Dhs
Famotidine                         Famodar 10 tab                              16.50 Dhs
                                   Pepcidine 40mg 30tab                        274.00Dhs
                                   Pepcidine 20 mg 30 tab                      158.50Dhs
                                   Pepcidine 40 mg 10 tab                      96.00 Dhs
Nizatidine                         Axid 150 mg tab                             88.00 Dhs
                                   Axid 300 mg tab                             87.50 Dhs
Proton Pump Inhibitors:            Risek 10mg                                  90.00 Dhs
Omeprazole                         Risek 20mg                                  175.00Dhs
                                   Gasec 20mg                                  238.50Dhs
                                   Losec 20 mg 14 caps                         172.50Dhs
                                   Losec mups 20 mg 14 tab                     146.50Dhs
Lansoprazole                       Lanfast 30mg                                100.50Dhs
                                   Lanzor 30mg                                 110.50Dhs
Pantoprazole                       Pantozol 20mg 30 tab                        113.50Dhs
Antacids :                         Moxal plus (chewable) tab                   10.00 Dhs
Aluminium and Magnesium Hydroxide/ Moxal plus suspension 100ml                 6.50 Dhs


                                                                                            2
Simethicone                                Gastrogel                         12.00 Dhs
                                           Gastrogel                         4.00 Dhs
                                           Riopan (low sodium)               13.50 Dhs
                                           Malox                             16.00 Dhs
Sucralfate                                 Gastrofait                        20.00 Dhs

Antibiotics For H.Pylori :                 Amoxidin 500 mg                   34.00 Dhs
Amoxicillin                                Amoxil 500 mg                     80.00 Dhs
                                           Amoclan Forte 15 tab 625 mg       55.50 Dhs
Metronidazole                              Flagyl 400 mg                     28.00 Dhs
                                           Flagyl 200 mg                     19.00 Dhs
                                           Metrolag 250 mg                   18.50 Dhs
                                           Metrolag 500 mg                   29.00 Dhs
                                           Dumex 1g                          42.50 Dhs
                                           Dumex 500 mg                      25.00 Dhs
Clarithromycin                             Klacid 500mg 20 tabs              249.50Dhs
                                           Klacid 500mg 7 tabs               91.50 Dhs
                                           Klacid 250 mg 14 tabs             94.00 Dhs
Amoxicillin + Clavulanic acid              Augmentin 1g 14 tab               141.00Dhs
                                           Augmentin 375mg 20 tab            66.50 Dhs
                                           Augmentin 625 mg 20 tab           115.50Dhs
                                           Curam 625 mg                      81.00 Dhs
                                           Julmentine 375 mg 20 tab          50.00 Dhs

1.5 Choosing the optimal regimen :
Determining the least expensive strategy for managing H pylori infection depends on
various circumstances, such as the population being treated. Failure to eradicate the
infection results in recurring costs because of development of antimicrobial resistance,
recurrent ulceration, and in some patients, recurrent bleeding. Another main reason which
results in an increase in the cost of therapy is non compliance which can also worsen the
quality of life .


The most effective eradication and cost effective therapy for H.Pylori is:
    1) Omeprazole 20mg twice daily
    2) Clarithromycin 500mg twice daily
    3) Amoxicillin 1 g twice daily
Note that this therapy would cost about 272 DHS taking into consideration patient
compliance , i.e. , taking less medication . We can however lessen the price of the therapy



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by minimizing the dose but increasing the nos of administration , which would be very
difficult for the patient to keep track of how many medication he took per day. Also
another thing that should be noted is that if patient was allergic to penicillin , then another
triple therapy could be prescribed . We could also minimize the cost by increasing the
duration of therapy instead of 7days to two weeks .
1.6 The cause of Patient Non compliance could fall into two categories :
   A) Patient-related
              Misunderstanding of prescribing instructions
              Forgetfulness
              Denial of the illness or its significance
              No faith in the drugs effectiveness
              Reduction , fluctuation or disappearance of symptoms
              Concern about taking drugs( e.g., adverse effects , addiction)
              Financial concerns
              Physical difficulties (e.g. swallowing tablets or capsules, opening bottles ,
               getting prescription filled)


   B) Drug- related
          Adverse effects (real or imagined)
          Complex regimen (eg. Frequent dosing, many drugs)
          Similar-appearing drugs
          Unpleasant taste or smell
          Inconvenient or restrictive precautions (eg no alcohol or smoking)


1.7 Strategies for improving Compliance :
To improve compliance one has to enhance communication between the patient and
health care team members , assessment of personal and economic condition reflected in
the patients lifestyle , development of a routine for taking medication (eg , at mealtimes if
the patient has regular meals) , and provison of systems to assist taking medications (ie
devices that separate drug goses by day of the week , or medication alarm clocks that



                                                                                             4
remind patient to take their medications) ; and mailing or refill reminders by the
pharmacist to patient taking drugs chronically.


1.8 Treating the Complications of peptic ulcer disease
Bleeding peptic ulcer
Acid suppression or other cytoprotective agents have no role in arresting hemorrhage. A
number of studies have shown that endoscopic injection therapy is an effective
haemostatic procedure.
Pyloric stenosis
Conventional treatment with acid –suppressive therapy is helpful in this case. If medical
therapy fails to relieve the obstruction , endoscopic balloon dilatation or surgery may be
required.


Stress Ulcers
Severe physiological stress such as head injury , surgery or burns may induce superficial
mucosal erosions or gastro duodenal ulcerations. These may lead to hemorrhage or
perforation. Diminished blood flow to the gastric mucosa , decreased cell renewal ,
diminished prostaglandin production and occasionally , acid hyper secretion are involved
in causing stress , ulceration. Intravenous histamines , H2 receptor antagonists (cimetidine
, ranitidine , nizatidine) , nasogastric tube administration of sucralfate (4 to 6g daily in
divided dose ) and titrated doses of antacids are used to prevent stress ulceration in the
intensive therapy unit.


1.9 Patient education

       Patients with diagnosed peptic ulcer disease require to be educated about the
current principles of the therapeutic management. This education should assure
adherence to prescribed medication and be directed at correcting any misunderstanding
about previous ulcer healing managements. In most patients a single treatment course is
required without the need of maintenance therapy.
       Patients receiving eradication therapy for H.pylori should be advised of the need
to treat the organism using a combination of three drugs for a short period of time. If


                                                                                               5
patients stop taking the medication too soon or miss some doses , the infection will not
clear up completely a and the ulcer may come back. Patient adherence is therefore very
important for successful ulcer treatment.
       The most appropriate drug and formulation should be chosen for each patient to
ensure adherence .For example Omerprazole capsules are unstable when removed from
original container and placed in a compliance aid .There is no liquid formulation of a PPI
commercially available for patients who cannot swallow tablets or capsules, in which
case an H2 receptor antagonist may be more suitable.
       Other points to consider in tailoring the medication the patient are: history of
adverse drug reaction , concomitant disease states and concomitant drug therapy. For
example , patients who are sensitive to penicillin require an eradication regimen which
does not include amoxycillin.
        Patients with renal failure require an adjusted dose of cimetidine or should be
prescribed an alternative agent whose dose does not need adjustment.
Patients must avoid alcohol when taking Metronidazole as they might have a disulfiram-
like reaction with sickness and headache. Misoprostol should not be used in pregnant
women , and women of child-bearing age should be warned appropriately.
Patients should be warned of the specific side effects to except from the regimen that has
been chosen for them and advised to seek the pharmacist’s advice when purchasing over-
the-counter analgesic preparations. Asprin- and ibuprofen- containing preparations
should be avoided , and paracetamol- containing products advised.


1.10 Patient monitoring .
       Treatment success is measured by review of the patient which may include a urea
breath test and /or an endoscopy. Patients should be aware of what their review will entail
and when the review will take place. If patients comply with their medication the review
process may be kept to a minimum.
       Following eradication therapy some patients continue to experience symptoms of
abdominal pain. Patients should be reassured that these symptoms will resolve ,
spontaneously , but if necessary an antacid preparation can be recommended to relieve
symptoms until review. Patients receiving treatment for NSAID-induced ulceration


                                                                                           6
should continue their ulcer healing therapy , until review. Patients who are anemic
following a bleeding ulcer may be prescribed iron therapy. If patients suffer side-effects
such as constipation or diarrhea ,the dose of iron should be reduced.
Treatment with iron should be for at least 3 months. Iron preparations are best absorbed
from an empty stomach but if gastric discomfort is felt, it should be taken with food.
We should know that patients are more like to comply to their therapy if they have a good
relationship with their physician , in which they are included in the decision making and
the physician shows concern that they comply. It is very important to encourage patients
to ask questions and express their concerns , which can help them come to terms with the
severity of their illness and intelligently weigh the advantages and disadvantages of a
treatment regimen.
       Following review , some patients will require maintenance therapy with an ulcer-
healing agent. The duration of this therapy should be made clear to the patient and
potential adverse effects discussed.


1.11 Undiagnosed dyspeptic patient.
Patients may present themselves to the community pharmacist complaining of symptoms
of upper abdominal discomfort , retrosternal pain , heart burn , nausea and vomiting.
These patient seek advice with regard to symptom control. Its is important to clearly
establish what the symptoms are , how long the patient has had these symptoms and any
other medication they have taken.
Many diseases are associated with dyspepsia including peptic ulcer disease , gastro-
esophageal reflux disease , cancer of the stomach or pancreas, gastritis and galls tones.
During the history taking it is therefore important to establish whether or not the patient
has lost any weight , had blackened stool , jaundice or difficulty in swallowing all of
which are ‘alarm symptoms’ requiring urgent referral to the general practitioner.
Many drugs can giver rise to symptoms of dyspepsia. Drugs that decrease lower
oesophageal sphincter tone may give rise to gastro-oesophageal reflux , eventually
leading to oesophagitis .Several drugs are known to cause this , including anticholinergics
, tricyclic antidepressants and calcium channel blockers.




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        Smoking can also cause acid reflux. Patients taking over-the-counter NSAIDS
should be advised to discontinue this therapy and take an antacid to relieve symptoms.
Patients taking prescribed medication which may contribute to symptoms should be
referred to the general practitioner.    Patients with no alarm symptoms or complicating
drug therapy can be offered, symptomatic relief. If the patient has heart burn, an alginate
–containing antacid may be of benefit. Antacids are the first-line treatment, and patients
advised to return if symptoms are not controlled after 1 week of regular treatment. If
symptoms persist, another week of treatment with an over-the –counter H2 antagonist can
be advised.
     If symptoms persist after 2 weeks of over-the-counter medication, the patient should
be referred to the general practioner.
In addition to antacids, patients can be given lifestyle advice. Smoking is known to delay
ulcer healing and gives rise to acid reflux. Patients should be informed of this and advised
to give up smoking. Heavy alcohol consumption can cause gastritis; therefore appropriate
advice should be given.
Patients with heartburn should be advised to avoid tight clothing, especially around the
waist . Elevation of the head of the bed is helpful. The use of additional pillows does not
achieve the same benefit. Fatty foods , chocolate and caffeine are known to exacerbate
acid reflux. In general, patients are aware of the dietary products that make them feel
unwell and avoid them


1.12 Patient Instruction concerning the Ulcer Healing Drugs :
Antacids :

If antacids , do not relieve symptoms of indigestion , upset stomach or heart burn within 2
weeks , contact your health care practitioner. Diarrhea may occur with magnesium-
containing antacids , decrease the daily dosage , alternate doses ,with or switch to an
aluminum or calcium containing antacid.
Constipation may occur with aluminum –containing antacids; decrease the daily dosage ,
alternate doses with , or switch to , a magnesium-containing antacid. Refrigerating liquid
antacids may improve their palatability. Antacids may interfere with other medication ,;



                                                                                              8
take other medications 1-2 hours before or after antacids unless otherwise directed. If
tablets are used , chew thoroughly before swallowing and follow with a glass of water.


H2- receptor antagonists:

The effectiveness of H2- receptor antagonists in peptic ulcer disease may be decreased by
cigarette smoking. Discontinue or decrease smoking , or avoid smoking after the last dose
of the day. If symptomatic relief is not obtained in 2 weeks with over-the counter
medication, contact your health care practitioner. If you miss a dose, take it as soon as
possible. If it is almost time for your next dose, skip the missed dose and return to your
usual dosage schedule. Do not double doses.


Proton Pump Inhibitors :
Swallow capsule whole or open the capsule and sprinkle the granules on applesauce or
place in apple or orange juice and take before meals. Swallow capsule or intact granules
immediately without chewing. The effectiveness of PPIs in peptic ulcer disease may be
decreased by cigarette smoking. Even though symptoms may improve, continue
treatment for the duration of therapy unless instructed otherwise.


Sucralfate :
Take this drug with water on an empty stomach, 1 hour before each meal and at bedtime.
Antacids may be used as needed for pain relief , but do not take them within 30 minutes
before or after sucralfate. Take potentially interacting drugs 2 hours before sucralfate in
order to avoid or minimize drug interactions. Even though symptoms may decrease,
continue treatment for the duration of the therapy unless instructed otherwise.




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1.13Adverse reaction to ulcer – healing drugs :


Drug                                     Adverse reaction
                  Common                                            Rare
Cimetidine        Dizziness                         Liver dysfunction
Ranitidine        Fatigue                           Blood disorders
Famotidine        Rash                              Bradycardia
Nizatidine        Headache                          Confusion
                                                    Interstitial nephritis (Cimetidine)
                                                    Gynaecomastia (Cimetidine)

Omeprazole        Diarrhea                          Photosensitivity
Lansoprazole      Headache                          Angioedema
Pantoprazole      Nausea                            Alopecia
                  Constipation                      Paraesthesia
                  Abdominal pain                    Confusion
                  Skin rashes                       Myalgia
                  Dizziness                         Taste disturbance
                  Fatigue                           Gynaecomastia
                                                    Leucopenia
                                                    Liver dysfunction


Sucralfate        Constipation                      Nausea
                                                    Dry mouth
                                                    Skin rashes
                                                    Dizziness
                                                    Headache

Bismuth           Darken tongue                     Nausea
Chelate           Blacken faeces
                  Bismuth absorption
Misoprostol       Diarrhea                          Nausea
                  Abdominal pain
                  Menstrual disorders



1.14 Drug interactions :
It is defined as the modification of the effect of a drug by prior or concomitant
administration of another drug .




                                                                                          10
Mechanisms of drug interactions :
Drug interactions occurs according to the mechanism involved , these mechanisms may
be divided into :
   A) Pharmacokinetic , which means one drug alters the absorption , distribution ,
       metabolism or elimination of another drug.
   B) Pharmacodynamic. Which means the effect of one drug are changed by the
       presence of another drug at its site of action.
Susceptible patients :
The probability of a drug interaction increases with the number of drug received by a
patient .


Drug interaction are more likely to occur in specific patient groups :
   1) Elderly
   2) Critically ill patient
   3) Those with undergoing complicated surgical procedures.
   4) Patients with impaired organ function , which may effect the elimination of drugs
       from the body , thus increasing the likelihood of drug interactions.
   5) Patients with chronic conditions such as diabetes , asthma , or epilepsy.




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Examples of drug interactions with Ulcer –Healing Drugs
Drug           Interaction and effect     Mechanism
Cimetidine     B –Blockers                Effect Clearance
               Calcium Channel            Effect Clearance    absorption
               Blockers                   Effect Clearance
               Benzodiazepines            Effect Clearance
               Imipramine                 Effect Clearance
               Phenytoin                  Effect Clearance
               Theophylline
               Warfarin
Ranitidine     Theophylline               Effect Clearance
Famotidine     No reports of clinical
Nizatidine     importance
Omeprazole     Methotrexate               Effect Clearance
               Phenytoin                  Effect Clearance
               Benzodiazepines            Effect Clearance
               Warfarin
Lansoprazole   To date no reports of
Pantoprazole   clinical importance.
               Limited Data.
Bismuth        Tetracyclines              Effect Absorption
chelate
Sucralfate     Warfarin                   Effect Absorption
               Phenytoin                  Effect Absorption
               Thyroxine                  Effect Absorption
               Tetracycline               Effect Absorption
Antacid        Tetracycline               Effect Absorption




                                                                              12
           1.16 Considerations in Selecting a Strategy for the Initial Management
           of Dyspepsia.


Strategy                 Advantages                                    Disadvantages


Option 1: endoscopy      Gold standard test to exclude    Expensive Invasive Not cost-effective or
                         gastroduodenal ulcers, reflux   practical in young patients without alarm
                         esophagitis and upper           symptoms Rarely, endoscopic
                         gastrointestinal cancers .      complications
                         Beneficial because up to 40
                         percent of patients have an
                         organic cause of dyspepsia
                         Provides adequate patient
                         reassurance Test of choice
                         for targeting therapy
Option 2: empiric        Least expensive strategy        Cost advantage is lost with symptom
treatment with acid      Rapid relief of symptoms        recurrence or lack of response.
suppression              High response rate              High rate of symptom recurrence May
                         May reduce the number of        promote inappropriate long-term
                         endoscopies                     medication use May delay diagnostic
                                                         testing May mask the symptoms of
                                                         malignant ulcers Likely to provide the
                                                         least patient reassurance Rarely, serious
                                                         side effects (i.e., gynecomastia or
                                                         hematological disorders)

Option 3: test for       Seems to be an acceptable       May increase levels of antibiotic
H.PYLORI and treat if    approach and the least          resistance.
test is positive         expensive strategy in H.        Relies on accurate H. pylori testing.
                         pylori-sensitive patients .     May result in over treatment because of
                         May reduce the number of        false-positive results or under treatment
                         endoscopies                     because of false-negative results.
                                                         Benefits in patients with functional
                                                         dyspepsia are likely to be small or non-
                                                         existent .
                                                         Cancer and ulcer disease may be missed .
                                                         Patient inconvenience because of
                                                         complicated drug regimens .May result in
                                                         serious side effects .


Option 4: empiric        Avoids cost of H. pylori        May increase levels of antibiotic resistance


                                                                                           13
eradication of H.         testing and endoscopy (actual       Benefits in patients with functional
pylori.                   cost savings may be modest if       dyspepsia are likely to be small or
                          patient eventually requires         nonexistent.
                          endoscopy) May reduce the
                          number of endoscopies.              Cancer and ulcer disease may be missed.
                                                              Patient inconvenience because of
                                                              complicated drug regimens



        Some patients without alarm symptoms or signs:
        1.)Any patient over the age of 45 with troublesome dyspepsia .
        2.) Patients under the age of 45 with troublesome dyspepsia who are positive for
        Helicobacter Pylori on non-invasive testing.
        Patients with dyspepsia in whom endoscopy is inappropriate:-
        1.) Patients known to have duodenal ulcer who have responded symptomatically to
        treatment.
        2.) Patients under 45 asymptomatic after a single episode of dyspepsia.
        3.) Patients who have recently undergone a satisfactory endoscopy for the same
        symptoms.


        1. 17 Dyspepsia :
        Dyspepsia is a group of symptoms which alerts doctors to consider disease of the upper
        GI tract. It is not a diagnosis and includes symptoms of upper abdominal discomfort,
        retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety and
        heartburn amongst others. A firm clinical diagnosis can be difficult on the basis of these
        symptoms as few symptoms are discriminatory. Many diseases cause dyspepsia and these
        include peptic ulcers, oesophagitis, cancer of the stomach or pancreas, and gallstones.
         In a large proportion of cases no clear pathological cause for a patient’s symptoms can
        be determined.


        1.18 What is required during patient questioning ?
        Symptoms
               Heart burn
               Difficulty in swallowing


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    Flatuence
    Duration of symptoms
Age
    Adult , child
Previous history

Details of pain
      Where is the pain?
      What is its nature ?
      Is it associated with food ?
      Is the pain constant or colicky
      Are there any aggravating or relieving factors?
      Does the pain move to anywhere else?
Associated symptoms
    Loss of appetite
    Weight loss
    Nausea / Vomiting
    Alteration in bowel movement
Diet
    Any recent change of diet , Eating habits
    Alcohol consumption
Smoking habit

Medication that may lead to ulceration

   Medication that already tried
   Any specific allergic condition to any medication.
Any associated diseases ?
   Systemic Illness
   Diabetes mellitus
   Sickle cell disease
   Cystic fibrosis
   Crohn's Disease

Age:

The symptoms of reflux and oesophagitis occur more commonly in patients aged over
55.Heartburn is not a condition normally experienced in childhood, although symptoms
can occur in young adults and particularly in pregnant women. Children with symptoms
of heart burn should therefore be referred to their doctor.




                                                                                    15
Symptoms/associated factors
A burning discomfort is experienced in the upper part of the stomach in the mild
line(epigastrium) and the burning feelings tends to move upwards behind the breastbone
(retrosternally). The pain may be felt only in the lower retrosternal area or on occasion be
felt right up to the throat , causing an acid taste in the mouth.
Deciding whether or not someone is suffering from heartburn can be greatly helped by
enquiring about precipitating or aggravating factors. Heartburn is often brought on by
bending or lying down. It is more likely to occur in the overweight and can be aggravated
by a recent increase in weight. It is also more likely to occur after a large meal , It can be
aggravated and even caused by belching. Many people develop a nervous habit of
swallowing to clear the throat,. Each time this occurs, air is taken down into the stomach,
which becomes distended . This causes discomfort, which is relieved by belching but
which in turn can be associated with acid reflux.


Pregnancy :
It has been estimated that as many as half of all preganat women suffer from heart burn .
Pregnant womern gaed over 30 are more likely to suffer from the problem. The
symptoms are caused by an increase in intraabdominal pressure and incompetence of the
lower oesophagel sphincter.


Diet and Smoking habits:
Fatty foods and alcohol can cause indigestion , aggravate ulcers.
Smoking predisposes to , and may cause indigestion and ulcers. Ulcers heal more slowly
and relapse more often during treatment in smokers, The pharmacist is in a good position
to offer advice on smoking cessation, perhaps with recommendation to use nicotine ,
replacement therapy , in the form of patches or gum.




Medicines already tried :
Anyone who has tried one or more antacids without improvement or whose initial
improvement in symptoms is not maintained should see the doctor.



                                                                                            16
Other medicines being taken :
Gastrointestinal (GI) side effects can be caused by many drugs, so it is important for the
pharmacist to ascertain any medication which the patient is taking.
Non-steriodal anti-inflammatory agents (NSAIDS) , such as ibuprofen , indomethacin
and piroxicam have been implicated in the causation of ulcers and bleeding ulcers ,
Sometimes these drugs cause indigestion . Elderly patient are particularly prone to such
problems and pharmacists should bear this in mind. Severe or prolonged indigestion in
any patient taking a NSAID is an indication for referral. Particular care is needed in
elderly patients , when referral is always advisable.


____________________________________________ Section 2
Case No. 1

Patient Details:

A fifty-two-year old , Sudanese male , and is currently married. He is admitted on :
08/March/2001.

Past History:
Patient complained of localized backache in previous 2 months, which increases on
prolonged sitting. Patient had upper abdominal pain situated in midline for last 3 years on
and off, and is more on an empty stomach. It is associated with increased flatulence.
Patient is a smoker and smokes 20 cigarettes a day for the last 30 years and is a non-
alcoholic. No history of Diabetes mellitus, Jaundice or Tuberculosis. Taken Celedrax
200 bd for 7 days.
Present History:
Patient complained of increase in severity of abdominal pain for last 3 days and it is not
associated with vomiting or nausea. No history of loss of weight or appetite.




                                                                                         17
Associated signs and symptoms:
On examination: patient is well built, and is not pale , pain in upper part of the abdomen.
Abdomen is soft , tenderness is detected in the epigastric region (+) and in hypochondrial
region , No organomegaly present , small
umbilical hernia present. Vital signs are normal.
He passed loose stools 3-4 times a day, which is associated with mucus. Urine is normal
and no burning sensation is felt. Pain is not radiated either to back or along the
reterosternal area.


Laboratory test / Further examination :
       Stool RE with occult blood.
       Patient was advised to come on empty stomach at 8:00 AM to undergo Upper
        gastrointestinal endoscopy (UGI scopy).
       Biopsy for H.pylori (CLO) test.
On 9/March/2001:
Stool RE results was found to be normal.
The (UGI scopy ) results showed :
       Oesophagus at GE junction bleeds on touch , Oesophagitis present.
       Stomach , fundus , body antrum are severely inflamed and superficial gastritis
        present , mucosa appears slightly oedematus.
       Duodenum : D1 evidence of duodenitis present , no ulcers found. D2 was found to
        be normal.
       CLO test for H.pylori was found to be (+)ve.
Advised:
       Patient was advised to take a bland diet.
       Should stop smoking.
       Patient was prescribed a Triple therapy regimen for eradication of H.Pylori :
           1. Capsule Amoxicidin ( Amoxicillin) 1g Bid for 14 Days
           2. Tablet Klacid (Clarithromycin) 500mg Bid for 14 days.
           3. Capsule Gasec ( Omeprazole) 20 mg Bid for 14 days.



                                                                                         18
        Also An antacid Mucain gel 2 tsf Tid for 14 days.
        Patient then have to review after 13 days.
On 16/March/2001:
Patient was admitted to the orthopedics department , and complained of Back pain in
lumbar area.
Advised:
        Patient was instructed to perform regular gradual back exercise.
        Patient was prescribed :
            1. Tablet Vioxx (Rofecoxib) 12.5mg daily for 10 days.
            2. Capsule Pharmaton (multivitamin) once daily for 30 days.
            3. N.M calcium bid for 30 days.


On 23/March/2001:
Patient feels much better and is comfortable. Pain on abdomen only on full stomach and
has loose stool, otherwise is normal.
Advised:
        Patient was prescribed :
            1. Cap Gasec (Omeprazole) 20 mg once evening for 1 month.
            2. Patient has to review AFTER THREE MONTHS FOR (Urea breath test
Laboratory test and further investigation :
Stool Analysis                 Urine Analysis                      Chemical Test
Color         Brownish         Macroscopic       Normal            Random Blood     Normal
                                                                   Sugar            (
Consistency     Formed         Color             Pale yellow       Albumin          Normal
Blood           ------------   Appearance        Normal            Bile salts       Normal
R.B.C           ------------   Sp.Gravity        ---------------   Microscopic Test
Pus Cells       ------------   Reaction          Acidic pH         Pus Cell         4-
                                                 5.5                                6/HpF
pH              ------------ Random Urine        Absent            R.B.C            4-
                             sugar                                                  6/HpF
Occult          Absent                                             Casts            Absent
blood
                                                                   Crystals        Absent




                                                                                        19
Diagnosis :
Patient is diagnosed to have Oesophagitis , severe gastritis and duodenitis and positive for
Helicobacter pylori.


Comment :
      Patient was a smoker , and this is one of aggravating factors to peptic ulcer
       disease. So patient was advised to stop smoking.
      Patient was advised to take a bland diet , since fatty foods can make the
       oesophageal sphincter less competent by reducing its pressure and therefore
       contribute to symptoms.
      It is very important that patient should comply to the triple therapy regimen , so
       that to avoid the recurrence of the helicobacter pylori.
      It is also very important to state to the patient the importance of the follow
       up , for ensuring the complete , eradication and effectiveness of the treatment
       Using a Urea breath Test.

Case No.2

Patient Details :
A fifty-year-old , Indian female , and is currently married. She is admitted on :
13/Jan/2001.

Past History :
She is known to have hyperlypidemia , gestational Diabetes mellitus , Cervical
sparindylosis .Known to be allergic to Paracetamol (panadol). Two weeks back patient
developed abdominal disturbances with reterosternal pain. She was given medication at
Central Hospital. She was CLO test positive , and was dissolved on 6/Jan/2001 on
Losec (Omeprazole) / Amoxid  (Amoxicilin) / Klacid  (Clarithromycin) ,


Present History:
Patient complained that abdominal pain is more severe even after going to Central
hospital for treatment.




                                                                                            20
Associated signs and symptoms :
Patient complained of abdominal disturbances , vomited couple of times , and has severe
jerky motion of both hands and legs .
Patient didn’t have any blood in stool (malena), no loose stool. Patient is not feverish.
On examination , patient is comfortable , oriented. B.P = 140/100 , C.V.S = normal , liver
part palpable , no free fluid , Blood Sugar (+).


Laboratory test and further investigation:
      U/S (ultra sound) scan , of Abdomen and pelvis (result : no sonographic
       abnormality noted in the abdomen and pelvis)

Test                                          Result                  Normal reference.
E.S.R (erythrocyte sedmintation rate)         30 mm/1st Hr            1-30
Hb                                            13.2                    12.0-16.4g/dl
Total WBC                                     9.9                     4-11 g/dl
Total RBC                                     4.5                     4.2-5.4 x1012/L
Platlets                                      311                     150-450x109/L
Hematocrit                                    37                      36-47 %
MVC                                           83                      80-96fl
MCH                                           30                      26-32pg
MCHC                                          36                      32-36g/dl
Differential Blood count
Neutrophills                                  72               40-75109/L
Lymphocytes                                   26               20-45109/L
Monocytes                                     01               2-10109/L
Esonophills                                   01               1-6 109/L
Basophills                                    00               0-1
Random Blood Sugar                            155 mg/dl        70-140
Random Urine Sugar                            Absent
Na , K , Cl                                   Normal           (135-145),mmol/L Na
                                                               (3.5-5.2),mmol/L K
                                                               (95-110) mmol/L Cl
Liver function test
SGOT serum                                    Normal                  7-40
SGPT serum                                    Normal                  5-40
Total protein serum                           9.2gm/dl                6.2-8.2
Globulin                                      4.8                     1.6-3.6

Later was reviewed on 10/March/2001 by gastroentrologist and advised to continue with
the same medication.


                                                                                            21
   1) Losec (Omeprazole) 20 mg twice daily.
   2) Amoxid  (Amoxicilin) 1g twice daily.
   3) Klacid  (Clarithromycin) , 500 mg twice daily.

Diagnosis :
Patient was CLO positive , and under went treatment for H.pylori. She is known to have
Diabetes mellitus and hyperlipidemia .
Comment :
  1) Associated diseases like diabetes mellitus and hyperlipidemia are risk factors for
       getting peptic ulcer disease. As we can see from the laboratory result , her random
       blood sugar is still above normal and I would request if she would refer to her
       physician , for a better control of the blood sugar level.
   2) Patient was asked if she was allergic to any medication and she was allergic to
       paracetamol , so she should avoid any NSAID , and if she would want to use
       them , she should ask her doctor .
   3) As we can see here that patient went to Central hospital and was diagnosed with
       CLO test positive on the 6th Jan.2001 . But after two weeks later patient still
       seems to complain of abdominal disturbances.
   4) In my point of view , I would suggest another therapy since patient may be
       resistant to the antibiotic therapy of H.pylori , or that patient require a longer
       treatment , for eradication using the same triple therapy given.
   5) IT is very important to state to the patient the side effects of the current therapy ,
       for example a metallic taste , because of clarithromycin , and patient should
       inform their doctor if they have any kind of allergy or side effect from the
       medication. Since it is important to ensure patient compliance to the therapy.
Case No.3

Patient Details:
A forty-four-year old , Pakistanian male was admitted on : 28/Dec/2000.




Past history :


                                                                                            22
History of lost of weight of around 23kg in 6 months. History of occasional vomiting and
nausea. No ill history in the family. Patient is known to have tremors in hands and
palpitation.


Present History:
Patient complained of epigastric pain for four days . On 28/Dec/2000 patient took Tablet
Histac 150 BD for seven days , Gastrogel liquid 15 ml .


Associated signs and symptoms:
Patient complained of upper abdominal pain since one week , pain is severe during the
night and on empty stomach , and it decreases after taking food . No history of vomit
today , Efebrile . Epigastric tenderness , No history of malena , or haemetemesis. Patient
passed loose stools since 2 days. Nicturition normal. Patient showed tremor in the hand
and palpitation , and is intolerance to heat.
Examination on 29/Dec/2000         : patient looked thin , tensed , Pulse : 100/min , B.P :
140/60 mmHg , not pale , Pretobial myscoedema (+) , Tremors in hand (+) , Abdomen is
soft , liver palpable firm and non tender , no other organmegaly.
Neck :- Thyroid is enlarged fully , moves on deglutition , venous hum could be heard (+).
Heart :- Generalized systolic murmur +


Advised :
      Patient was advised to come on empty stomach to under go GI scopy.
      Lab Test on thyroid profile was done , T3,T4,TSH
      Biopsy for H. pylori (CLO) Test.
Results of the Endoscopy:
      Upper gastrointestinal endoscopy showed : Oesophagus : normal , Stomach ,
       Fundus , Body were normal , however in the antrum , severe antral gastritis was
       found. In duodenum : showed D1 large posterior wall ulcer active , bleeds on
       touch , with severe duodenitis and deformed duodenal cap. D2 Could not be
       negotiated because of the deformed Duodenum.
      Patient was positive for CLO test.


                                                                                              23
Patient was prescribed the following drugs :
           1. Capsule Amoxidin (Amoxicllin) 500 mg Bid for 14 days
           2. Tablet Metrolag (Metronidazole) 500 mg Bid For 14 days
           3. Mucogel 2 tsf 3 times daily.
Patient should come after 2 days for Review .
On 31/Dec/2000.
Patient was found to be thyrotoxic , diffuse toxic goiter.
Patient was prescribed :
                        Tab. Neomercayole (5mg) 10mg Tid for 15 days.
                        Tab Inderal (10 mg) , patient should take 20 mg Tid for 1 month.
On 20/Feb/2001.
Patient feels much better , comfortable , no abdominal pain , has good appetite , he
gained 7 kg weight. Bowel and bladder habits are normal. Pulse is 108/min , regular .
Thyroid swelling still present. Patient has stopped Neomecayole and Inderal , one month
back , lost follow up.


Patient was advised to :
      TO continue Tab Neomercayole  (5mg) 10mg Tid for 15 days.
      Tab Inderal  (10mg) , take 20 mg Tid .
      B complex with zinc 1 daily for 15 days.
Discussed about surgery and radioactive iodine for the permanent cure of thyrotoxicoses .
Laboratory test :
Thyroid Profile               Results        Normal reference
T3 serum                      480 ng/dl      82-179
T4 serum                      279 nmol/l     58-161
TSH Third gene , thyroid 0.002 MIU/L 0.4-5
stimulating hormone


Diagnosis :




                                                                                        24
      Thyrotoxicoses with acute Gastritis (active Duodenal ulcer in the first part of the
       duodenum with severe Duodenitis , and antral gastritis with Duodenal cap
       deformity.
Comments :
      It can be clearly evaluated from the symptoms that the patient is suffering from
       duodenal ulcer, and that is confirmed by the endoscopy.
      Patient is known to have thyrotoxicosis , and during therapy , we realized that
       patient stopped taking the antithyroid drug and therefore the swelling of the
       thyroid gland was still there, However for permanent treatment the patient must
       undergo surgery , radioactive iodine , therapy.
      Patient was known to have tremors , and a (B-Blocker) Inderal  is given , to
       reduce his tremors and anxiety.


Case No . 4

Patient History :
A fifty-two-year old Egyptian male , who is currently married , is admitted on :
9/Nov/2000

Past History :
Patient is known to have hypercholestrolaemia for 2 years , and is currently on Lipitor 20
mg. Has no known drug allergy. History of pain in epigastric region since 1 year.


Present History :
Patient complained of epigastric pain few days and headache.


Associated Signs and Symptoms :
On examination BP 150/90 mmHg , patient complained of headache , and was admitted
for lab tests. Patient is Obese 106 Kg.




Laboratory tests/Further investigation:


                                                                                          25
Cholesterol    291
Triglycerides 121
HDL            46
LDL            189
FBS            91
FBC             Normal
ESR            04
Bld Urea       28
Creatinine     1.0
Urine R        Normal
CpK            292 (24-195)
SGOT           36
SGPT           48 (5-40)

Patients was prescribed the following drugs :

      Simepan (20 mg) B.D
      Liseol 40 mg O.D
      Garlic Caps
      Advised to stop lipitor
      Patient has to repeat test after a month.
On 23/Dec/2000:
Patient had pain which radiated down to the right arm. Was advised to take :
      Cataflam
      Voltaren
      Tab Talagavit 1 Bid daily.




On 11/Jan/2001 :



                                                                               26
Patient repeated test :

Test                                           Normal range

CPK 105                                        24-195
SGPT 62                                        5-40
Cholestrol 296                                 200-239
LDL 240                                        130-159
SGPT ALTY 55                                   5-40
Creatine phosphate serum 232                   24-195


Patient complained of epigastric pain and has history of food sticking onto the epigastric
region even for water. History of regurgitation during lying posture. History of nausea
and retrosternal burning pain present . No history of vomiting, and no loss of appetite or
weight. On examination patient was comfortable. Epigastric tenderness was present


Patient was prescribed the following medication:
      Tablet Apo.Ranitidine 300mg once daily
      Gastrogel 2 tsf Bid
      Tablet Prepulsid 10 mg twice daily for ten days.
On 13/Jan/2001:
Abdominal scan , showed , pancreases poorly visualized , liver has fatty infiltration.
On 3/Feb/2001 :
Upper gastrointestinal endoscopy revealed , severe reflux oesophagitis with hiatus hernia
, and relaxed GE junction , mild gastritis and duodenitis. CLO test for H.pylori was
positive.


Patient was prescribed the following medication :
      Bland diet for 3 weeks
      Tab Metrolag ( Metronidazole) 500 mg three times for 14 days
      Capsules Amoxcidin( Amoxicillin) 500mg three times for 14 days
      Capsules Gasec ( Omeprazole) 20 Bid for 14 days.



                                                                                          27
      Gastrogel 2 tsp Tid
      Tablet primperan ( Metoclopromide) Bid for 14 days.
      Lipitor (for hyperlipidemia) 10 mg./


Diagnosis :
Patient has got reflux oesophagitis and is positive CLO test. Known
hypercholesterolemia.


Comment :
      Patient was found to have low levels of HDL , and is known hypercholestima ,
       but patient was on lipitor and was told to discontinue it because of poor control
       of cholesterol levels.
      Note that primperan given to patient to avoid any nausea and GIT disturbances.
      Patient also is obese and should be advised to loose weight and should be asked if
       there is any history in the family of obesity of hypercholestrolima.
      One study found an association between H. pylori and migraine headaches in
       people who also have gastrointestinal problems. Eliminating the bacteria reduced
       the frequency and intensity of migraines in half of these patients
Case No.5
Patient Details:
An 11 year-old otherwise healthy girl presented to the emergency department.


Past History:
She reported taking ibuprofen three to four times per week for five months for muscle
aches or menstrual cramps. She was occasionally given an 800-milligram dose by her
mother. She had never been on steroids, and there was no personal or family history of
peptic ulcer disease or endocrine problems. She had no prior surgeries.




                                                                                         28
Present History :
She had last taken ibuprofen the day before the pain began. Sudden onset of severe, sharp
mid-epigastric pain approximately 20 hours earlier. She subsequently began having
episodes of nausea and vomiting, especially after trying to eat or drink.


Associated signs and symptoms :
On physical exam, she had a temperature of 38.6 degrees , a pulse of 120 and a blood
pressure of 130/74. She was sitting up in bed with her knees flexed, avoiding sudden
movements. She had diminished bowel sounds. Her abdomen was notably soft, but with
exquisite tenderness in the mid-epigastrium. She was also slightly tender in the right
lower quadrant. She had negative Rovsing's and obturator signs but a positive heel drop.
Rectal exam revealed light-brown, heme negative stool.


Laboratory Test /Further investigation:
      Studies revealed a white cell count of 23.31-thousand.
      Her hematocrite was 40.2, and her blood type was B-positive.
      Abdominal x-rays revealed air-fluid.
      Levels and free air under the right hemi diaphragm.
      A nasogastric tube was placed without return of bloody fluid.
      There was a perforation through the anterior portion of the pre-pyloric region of
       the stomach. No other ulcers or perforations were noted.
      There was no frank pus in the peritoneum, but some of the gastric contents had
       tracked down into the right lower quadrant. The perforation was repaired using a
       patch of omentum.


Diagnosis :
Pre-operative diagnosis of perforated gastric ulcer, the patient was taken to the operating
room. Laparo-scopy confirmed the diagnosis of perforated gastric ulcer. The post-
operative course was uncomplicated. A serum gastrin level came back normal. She was
discharged on hospital day seven and instructed to avoid all non-steroidal
antiinflammatories.


                                                                                           29
Follow-up :
Gastro duodenoscopy two months later demonstrated healing of the mucosa with no signs
of gastritis and a negative rapid urease test. Antral and fundal biopsies were consistent
with normal mucous. The duodenal bulb was also visualized and appeared normal.
Comment :
Secondary ulcers generally present more acutely than primary ulcers (the majority of
which are now known to be due to Helicobacter pylori). Secondary ulcers often do not
present until a complication such as hemorrhage or perforation develops, as in this case.
Hence, they have a higher need for surgery and a higher morbidity and mortality rate.
      Any patient given a non steroidal anti-inflammatory drug (NSAID) should be
       cautioned about the risk of gastritis and/or gastric ulceration. Parents given
       prescriptions for NSAID’s should be instructed not to give the medication to their
       children. A patient who is believed to have sustained a gastric ulcer secondary to
       NSAID’s should avoid any further use of them. If a patient must be on an NSAID,
       then the supplemental concurrent use of misoprostol should be considered.
      A patient with a perforated ulcer will present with a history of epigastric
       abdominal pain that suddenly became diffuse. There may be pain in the right
       lower quadrant as anteral contents track down the right gutter. This may mimic an
       appendicitis.
      On exam the patient is often febrile with tachycardia and hypotension, and lies
       still to avoid exacerbating the pain. The knees may be flexed. Bowel sounds are
       diminished to absent. The abdomen is very tender and is often described as
       boardlike, though not so in this case.
      Laboratory tests reveal an elevated white cell count, and an upright abdominal
       Roentgenogram may reveal free air under the diaphragm.
Case No.6
Patient Details :
A 32 year old female , from U.A.E was admitted on : 20/march/2001.


Past History :




                                                                                            30
She has history of abdominal pain last one year with recurrent episodes of spasms and
dyspeptic symptoms and loose stool. She Underwent upper gastroscopy in Al Jazeera
hospital one year ago and was told that everything was normal. She has no known drug
allergy . She is also known to have migraine headache, and was given Excedrin
(Acetaminophen, aspirin, Caffeine). Previous medication that she took for her spasms
were Imodium and Dusphatalin .


Present history :
Pain is more in the upper abdomen radiating to the back to either side. She has no
retrosternal pain , no vomiting and no loss of appetite.
Was advised to come next day on empty stomach to undergo endoscopy.


Laboratory test / Further examination :
1) Endoscopy results showed :
      Oesophagus was normal , relaxed GE sphincter.
      Stomach – Fundus , few ulcers seen
         Body  Gastritis
        Antrum  Multiple ulcers , studded all around the circumference of the antrum .
       There is an ulcer on the lesser, which is significant.
      Pylorus  Normal.
      Duodenum  D1 severe duodenitis , no big ulcer , D2 is normal.
2) Patient under went CLO test for H.pylori and was found to be negative.


Test                         Result    Normal value
Amylase                      148       <220 u/l
Liver function test
SGOT, Serum                  48        7-40
SGPT , Serum                 114       5-40
Total protien serum          6.8       6.2-8.2
Alkaline phosphate serum 129           30-130 ,130-530




                                                                                        31
Albumin serum                3.8          3.7-5.3
Globulin serum               3.0          1.6-3.6
Bilirubin serum              0.2          0.2-1.5
Hb                           Normal


Diagnosis :
Patient is diagnosed to have duodenitis , gastritis with antral ulcers. Patient found to be
CLO test (-ve).


The following medications were advised :
     1) Tablet Apo Ranitidine 300 mg 1od x 1 week
     2) Syrup Gastrogel 2 tsf bid x 1 week.
On 25/ March/2001 :
Patient feels much better , Comfortable except for slight heart burn , no vomiting .
Appetite slightly reduced but she wants it to be like that only.
The following medication were advised:
     1) Tablet Apo Ranitidine 300 mg 10d x 3 weeks
     2) Syrup Gastrogel 2 tsf bid
     3) Tablet prepulsid 5 mg 1-0-1 x 10 days
Also C/O few varicosities of the thigh , O/E capillaries of vein seen. So advised to take
Tablet . Venuriton Forte 2-0-2 x10 days and then 1-0-1 x days , and after this 1-0-0 for 1
month to start treatment after her treatment course for her abdominal pain is over.
Comment :
           Patient had previous abdominal spasms which caused acute diarrhea and she
            underwent treatment for it.
           Since patient was found to be ClO test negative , so the only treatment that is
            required is ulcer healing , using Apo Ranatidine ( h2 antagonist) , gastrogel
            (antacid).
           She also complained of few varicosities of the thigh and was advised to take ,
            treatment only after her course for abdominal pain is over. This may be
            because of several reason :


                                                                                              32
          Patient compliance and so that patient would avoid missing a dose .Since as
           we can see the treatment course of varicose vein is very long .
          Ranitidine has no interaction with venuriton forte. Migraine treatment with
           Excedrin.

Case NO. 7

Patient details:

A 30 year old male from U.A.E was admitted on 21/March/2001.

Past history :
He complained of upper abdomen last 7 months almost everyday , but cant tell what time
it comes . Not associated with food , but feels burning after taking food. No history of
vomiting , nausea , or radiation of pain to back or to the sides . No loss of weight ,Bowel
and bladders habits are normal..


Present History :
Patient complained of increased bleching Patient was also found to have Tinea pedis of
the fore foot , and is undergoing treatment with Lamsil (terbinafine)AND note that


Associated signs and symptoms :
On examination patient was well built , not pale , abdomen was soft and epigastric
tenderness was found. No organmegaly was found. Patient is Obese class II ,Height of
169cm , Weight of 103 kg.
Prediagnosed as Gastritis. Advised to come on an empty stomach tomorrow morning at
8:30 for Upper endoscopy.
On 22March/2001:
The results of the upper endoscopy reveled :
      Oesophagus , is normal ,
      Stomach , Fundus lots of bile present and body is inflamed.
      Antrum , evidence of superficial antral gastritis present ,
      Pylorus wide and patent.



                                                                                           33
      Duodenum D1 Oedematous , no ulcer , D2 Normal.
Diagnosis :
Biliary gastritis due to relaxed pylorus , with mild duodenitis , no obvious ulcer . CLO
test for H.pylori is (-ve). Patient obese type II, and has tinea pedis undergoing treatment.
Advised to take the following medication :
   1) Tablet Apo Ranitidine 300mg 1 x 15 days.
   2) Syrup Gastrogel 2 tsf tid x 15 days
   3) Tablet prepulsid 10mg 1-0-1 x 15 days
Patient should review after 15 days.
On 7/April/2001:
Patient still feels pain in epigastric area , more on an empty stomach. History of increased
flatulence , fowel smelly stool , pain tolerable but irritation still present. No vomiting.


Advised to take the following medication:
   1) Capsule . Pariet (pantoprazole) 20 mg 1cap x10 days
   2) Tablet Gastrogel 1-1-1 x 10 days.


Comment :
              Obesity is one of the factors which could lead to ulcers , because of
               irregularity in eating .
              Patient has tinea pedis , which is undergoing treatment with Lamsil
               (Terbinafine)NOTE : Terbinafine has interaction with Cimetidine (Ulcer
               healing drugs)in which its plasma concentration is increased.
              Patient is obese male and cimetidine is not a drug of choice , since it
               would cause gynacomastia in male and patient is already obese. As we can
               see patient was first given H2 receptor antagonist , but after 15 days patient
               still felt pain , so he was given a much stronger inhibitor of acid secretion
               which is Proton pump inhibitor pantoprazole.




                                                                                              34
Case No. 8

Patient History :

A 45 year old oriental man with hematemesis.



Past History :
The patient grew up in Hong Kong and came to the US at age 20. He has a long history
of meal related epigastric pain, somewhat relieved by Tums and Rolaids. One year ago he
was told he could not donate blood because of a "liver virus". There is no history of
hepatitis or complications of cirrhosis. Two months prior to admission he injured his back
at work. No prior hospitalizations or operations. No family history of liver disease,
bleeding, or cancer.


Associated signs and symptoms :
On the day of admission he had two episodes of vomiting bright red blood. He estimates
the amount as several quarts. The during the day prior to admission he passed three loose
melenic stools. Two days prior to admission he ate some "bad fish" and had multiple
episodes of nausea and vomiting over a 24 hour period.


BP:          105/72 lying; 90/55 sitting
HR:          98 lying; 110 sitting


RR:          16


Temp         37


Weight       54.4 kg
Height:      5' 3''


General:     no lymphadenopathy; no wasting



                                                                                        35
Lungs:         Normal
 Heart


Abdomen: soft, no mass, no tenderness, liver not palpated
               but per cussed to 7cm span, spleen tip easily felt
Rectal:        normal; melena on exam finger




Laboratory tests:
Hgb (gm/dL)        12                   AlkP (U/L)           59
                                        ALT (U/L)            35
                                        AST (U/L)            29
                                        Amy (U/L)            80
Hct (%)            35                   Glu (mg/dL)          117
                                        Urea (mg/dL)         32
                                        Creat ( mg/dL)       .8
                                        Ca (mg/dL)           9
                                        Phos (mg/dL)         3.2
                                        UA (mg/dL)           4.5
WBC(x109/L) 11


Plt (x109/L)       260


Na (meq/L)         140
K (meq/L)          3.8




Diagnosis :
Acute upper gastrointestinal bleeding from a duodenal ulcer with a visible vessel in a
patient with chronic liver disease, perhaps due to hepatitis B infection.


                                                                                         36
Comment :
     The pulse and blood pressure, including changes with position, are useful to
      assess the severity of acute blood loss. This patient ad lost between 10-20% of his
      blood volume acutely.    If the history and physical examination suggest possible
      portal hypertension, medical and endoscopic therapy are initiated rapidly because
      the natural history of bleeding esophageal or gastric varices is to continue to bleed
      or re-bleed early after stopping.
     Patients with acute upper gastrointestinal hemorrhage and evidence from history
      and physical examination suggesting liver disease should have (after volume
      resusitation) immediate octreotide infusion and urgent endoscopy to treat possible
      varices.
     Patients with suspected ulcer bleeding should be given high dose proton
      pump inhibitors to prevent continued or re-bleeding. Those with clinical risk
      factors for continued or re-bleeding (hemodynamic instability, continuous
      nasogastric tube bleeding, bright red blood per rectum, age over 50, co
      morbid diseases, in-hospital bleeding)      should have urgent endoscopy for
      treatment of high risk ulcer (active bleeding, visible vessel, clot).
     Patients with suspected ulcer bleeding and few clinical risk factors for continued
      bleeding may be fed and possibly discharged once endoscopy confirms no ulcer
      stigmata predicting re-bleeding.
     Important points regarding the laboratory tests in patients with this condition
      include:
  1) In acute bleeding the hemoglobin level does not accurately reflect degree of blood
      loss.
  2) In this patient an upper gastrointestinal source was obvious from the history and
      physical examination. Patients with cirrhosis and portal hypertension may have
      normal laboratory values, but patients with abnormal prothrombin time, albumen,
      bilirubin, alkaline phosphatase, or transaminases should be considered as possible
      variceal bleeding.




                                                                                        37
Case No.9

Patient History :
Female patient not married , patient admitted on 17/Feb/2001


Past History :
Patient had pain in the abdomen since last June .Non smoker occasionally drinks.
Present History :
Patient complained of pain in the abdomen around the umbilical area since today
morning , pain is sometimes severe and colicky associated with many attacks of vomiting
and loose stool. He has a mild feverish feeling , no history of chills , pain is more in the
central abdomen , not radiating to the back or anywhere else. It is not associated with
food , No history of jaundice , diabetes or TB or HT .No history of loss of appetite , or
loss of weight.
No haemetemesis , malena , or mucos in the stool.


Associated signs and symptoms :
On Examination , patient is thinly built .appears pale , pulse is 90 /min
Abd :- Scaphoid , moves freely with respiration , no mass seen , soft tenderness around
the umbilical area m vague fullness in epigastric area , no mass organmeagly .
Advised C-Reactive protein , Hb stool occult blood , UGI scopy and CLO test .


Following medications were prescribed :
   1) Gavicon Syrup 30 ml stat
   2) Tablet Gastrobid 1 stat
   3) Inj . Valium 10 mg IM SOS


On 18/Feb/2001:
Patient much comfortable , not vomited , slept well . Abdomen , still mild tenderness ,in
the epigastric region .



                                                                                               38
Laboratory tests:
       Upper endoscopy revealed :
    1) Showed multiple superficial ulcers in the first part of duodenum with a patent
        pylorus and biliary gastritis.
       CLO test was negative.
    Patient was advised to take :
    1) Cap. Gasec 20 mg 1-0-1 x 14 days
    2) Gaviscon syrup 30 ml 1-1-1 x 14 days
    3) Tablet Buscopan 1 SOS
    4) Tablet Cisapride , 10 mg 1-0-1 x 14 days.
Was advised to come back for check up.


On 3/March/2001:
Patient is comfortable , symptomatically better , , no vomiting , no pain in the abdomen.
ON examination abdomen is soft and non tender .
Diagnosis :
Multiple superficial ulcers in the first part of duodenum with a patent pylorus and biliary
gastritis.


Comment :
    1) As we can see here its another classical case of peptic ulcer disease , and patient
        was found to be CLO test negative. So patient should be advised to avoid any risk
        factors like drinking alcohol that would lead to ulceration. Treatment of the
        superficial ulcers using ulcer healing drugs such as H2 antagonist , Proton Pump
        inhibitor (Gasec) , or and antacid ,(Gaviscon).
    2) Patient should be taught about the importance of compliance
    3) Patient was also give Valium (Diazepam)  INJ so that she could sleep well.
    4) Patient was also given Buscopan which is used in symptomatic relief of
        Gastrointestinal disorders characterized by smooth muscle spasm.




                                                                                         39
Case No. 10
Patient Details :
A 76-year-old Sudanese women .
Past History :
For several years, she had been taking 400 mg of etodolac twice a day for rheumatoid
arthritis; one tablet of enteric-coated, regular-strength aspirin a day; and 1 mg of warfarin
sodium a day for severe peripheral vascular disease she has iron-deficiency anemia,

Present History :
Complained for several weeks of abdominal pain and , fatigue.

Associated signs and symptoms :
On examination patient had abdominal tenderness and she was pale , sweating .
Laboratory test /Further examinations :
         Hematocrit of 24 percent,
         A positive test for occult blood in stool.
         After receiving a transfusion, she underwent upper gastrointestinal
         endoscopy, which revealed an aspirin tablet, with the enteric coating still intact,
within an ulcer of the gastric antrum. The tablet was removed with a forceps.


Diagnosis :
Gastric ulcer of the antrum.


Advised :
         Patient was advised to stop treatment with etodolac and asprin.
         Patient was given 30mg of Lansoprazole twice a day for two months.
After two months a second endoscopic examination showed complete healing of the
ulcer.
Comment :
         As I mentioned before , one of the risk factors for peptic ulcer is NSAIDS , and
          the patient here is taking Aspirin and Etodolac on a long term .



                                                                                               40
      When the endoscopy revealed a gastric ulcer at the antrum , the patient was
       advised to stop taking NSAIDS, and a strong Ulcer healing drug , such as
       Omperazole has been given .
      Also another complication of the ulcer is Hemorrhage and the patient has iron
       deficiency anemia , so in order to prevent this , you first have to prevent the
       causative factor .
      Patient should be taught the importance of compliance and should be told the
       possible side-effects to his current therapy and the reason of discontinuation.
      NOTE that patient is taking Warfarin for prophylaxis of embolisation in the
       rheumatic heart disease and atrial fibrillation , and treatment of venous thrombosis
       , and it is contraindicated in patient having Peptic ulcer. One of the side effects of
       Warfarin is hemorrhage and this may be the cause of Iron deficiency anemia.


Case No 11
Patient Details :
A Forty-eight-year-old Mr x was admitted from casualty.


Past History :
He had gnawing pain , but less severe and dyspepsia over the previous six months , but
that these had responded to antacids purchased from his local pharmacy , and had
resolved in a couple of days. He is a known hypertensive and has been taking Atenolol 50
mg for the past two years. He is known allergic to penicillin. He smokes at about 20
cigarettes a day and drinking 20 units of alcohol a week.


Present History :
He had a three-day history of intermittent stomach pains which had gradually become
more severe. For the past 10 days he has also been taking diclofenac 50 mg three times
daily for a knee injury sustained during a game of tennis.




                                                                                           41
Associated signs and symptoms:
He felt nauseated but had not been sick. Over the past 24 hours he had passed several
loose stools that he described as dark and foul smelling.
He described his pain as gnawing and generalized over his abdomen, and it worse at
night. On examination he was noted to be pale , sweating and showed with a blood
pressure of 120/60 mmHg and a pulse rate of 98 beats per minute. His abdomen was
tender .
He was advised to undergo an endoscopy for later in the days so he was made nil by
mouth.


Laboratory test and further examinations:
His relevant serum biochemistry and hematology tests were as follows:
Test results                                      Reference range


Sodium 135 mmol/L                                 137-750
Potassium 3.8mmol/l                               3.8-5
Urea 7.2 mmol/l                                   2.5-6.6
Creatinine 93 micromol/l                          80-150
Hemoglobin 10.3g/dl                               14-18
Mean cell volume 73                               78-94
Mean cell Hemoglobin 27 picogram                  32-36
Liver function test were within normal range


Results of endoscopy:
          His emergency endoscopy revealed global gastritis and a 1 cm ulcer crater in the
           duodenum adjacent to the antral mucosa. The ulcer was not bleeding .A sample of
           tissue was taken from the sump of antrum, a CLO test was performed and the
           result was positive.
Diagnosis :
Patient is known hypertensive undergoing treatment and he is gastric ulcer and he has
H.Pylori.


                                                                                          42
Advised :
         He was advised to stop smoking and drinking and avoiding stressful conditions.
         He was prescribed the following medication for eradication of H.pylori.
              1. Omeprazole 20 mg every 12 hours
              2. Clarithromycin 250 mg every 12 hours
              3. Metronidazole 400mg every 12 hours
Day 2 .
He was looking and feeling much better . He had not vomited since admission and his
abdominal pains had resolved , although he described his abdomen as tender.
He had received three units of whole blood and his hemoglobin had risen to 13.5g/dl.
Another Biochemistry results were done and results are :
Test results                    Reference range
Sodium 133 mmol/L               135-150
Potassium 4.8 mmol/L            3.8-5.5
Urea 6.5 mmol/L                 2.5-6.6
Creatinine 102 micromol/l 80-150


Day 3
Patient was complaining of a strange taste in his mouth and loose stools. His BP
140/100 mmHg.
Comment :
         Patient should be told the benefits of stopping smoking and reducing alcohol
          intake ,
         The importance of compliance to ensure complete eradication of the H.pylori
         Possible side effects to his current therapy. Since patient complained of a strange
          taste in his mouth and this is a common side effects to clarithromycin therapy and
          is rarely sufficient to discontinue therapy.
         He also had loose stool after therapy and this could be a result of his antibiotic
          therapy. If this worsen we could give loperamide .




                                                                                               43
      His blood pressure we could see that it is raised and so the antihypertensive
       therapy should be restarted and also there is no contraindication to represcribing it
       with the ulcer treatment.
      And I would also suggest if he would be given An Iron therapy , because of his
       low Iron due to his bleeding and its best after treatment.
      I would also suggest a Follow up treatment because he is hypertensive and at the
       same time to ensure the effectiveness of the eradication treatment using a Urea
       breath test.




___________________________________Section 3 Conclusion

I conclude that it is important to improve patient compliance by enhancing
communication between patient and health care team members. To provide a best
regimen cost effective for each patient, which mainly depends on patient factors , ex age ,
genetic factors , pregnancy , etc. We should first ask patient important question about
their symptoms, duration and then advise laboratory test , then upon these test , diagnose
the patient and give best treatment.




Biography
References :
      Clinical drug data
      BNF 41 March 20001
      Basic and Clinical Pharmacology by Katzung.
      Multimedia and Internet .
      Physicians Desk Reference.




                                                                                          44
______________________________________________Section 4

The Drug to Drug interaction are discussed in the following
Table :
Antacids has the following specific interactions:
Antacids should preferably not be taken at the same time as other drugs since they may
impair absorption
ACE Inhibitors                 Absorption of ACE inhibitor possibly reduced
Aspirin (also Benorilate)      Excretion of aspirin increased in alkaline urine
Azithromycin                   Reduced absorption of azithromycin
Bile Acids                     Possibly reduced absorption of bile acids
Bisphosphonates                Reduced absorption of bisphosphonates
Captopril                      Absorption of captopril reduced
Cefaclor                       Reduced absorption of cefaclor
Cefpodoxime                    Reduced absorption of cefpodoxime
Chloroquine and
                               Reduced absorption
Hydroxychloroquine
Ciprofloxacin                  Reduced absorption of ciprofloxacin
Deflazacort                    Reduced absorption of deflazacort
Diflunisal                     Reduced absorption of diflunisal
Digoxin                        Possibly reduced absorption of digoxin
                               Patient information leaflet advises avoidance of
Dipyridamole
                               antacids
Enalapril                      Absorption of enalapril reduced
Fexofenadine                   Reduced absorption of fexofenadine
Fosinopril                     Absorption of fosinopril reduced
Gabapentin                     Reduced absorption of gabapentin
Isoniazid                      Reduced absorption of isoniazid
Itraconazole                   Reduced absorption of itraconazole
Ketoconazole                   Reduced absorption of ketoconazole
Lansoprazole                   Possibly reduced absorption of lansoprazole
Levofloxacin                   Reduced absorption of levofloxacin
Mycophenolate Mofetil          Reduced absorption of mycophenolate mofetil
Norfloxacin                    Reduced absorption of norfloxacin
Ofloxacin                      Reduced absorption of ofloxacin
Penicillamine                  Reduced absorption of penicillamine
Phenothiazines                 Reduced absorption of phenothiazines
Phenytoin                      Reduced absorption of phenytoin


                                                                                         45
                             Reduced quinidine excretion in alkaline urine
Quinidine                    (plasma-quinidine concentration occasionally
                             increased)
Rifampicin                   Reduced absorption of rifampicin
Sulpiride                    Reduced absorption of sulpiride
Tetracyclines                Reduced absorption of most tetracyclines
Zalcitabine                  Reduced absorption of zalcitabine
Aluminium Hydroxide belongs to Antacids but has no additional
interactions information.
Hydrotalcite belongs to Antacids but has no additional interactions
information.


Magnesium Salts (oral) belongs to Antacids and has the following
interactions information:
Iron                         Magnesium trisilicate reduces absorption of oral iron
                             Magnesium trisilicate reduces absorption of
Nitrofurantoin
                             nitrofurantoin
                             Magnesium trisilicate reduces absorption of
Proguanil
                             proguanil
Sodium Bicarbonate belongs to Antacids and has the following interactions
information:
                             Increased excretion; reduced plasma-lithium
Lithium
                             concentration

Histamine H2-antagonists has the following specific interactions:
Cefpodoxime                  Reduced absorption of cefpodoxime
Itraconazole                 Reduced absorption of itraconazole
Ketoconazole                 Reduced absorption of ketoconazole
 Cimetidine belongs to Histamine H2-antagonists and has the following interactions
information:
Amiodarone                   Increased plasma concentration of amiodarone
                             Plasma concentration of amitriptyline increased
Amitriptyline
                             (inhibition of metabolism)
                             Plasma concentration of cimetidine possibly
Amprenavir
                             increased
                             Plasma concentration of tricyclic possibly increased
Antidepressants, Tricyclic
                             by cimetidine
Antipsychotics               Possibly enhanced effects of antipsychotics
Azapropazone                 Possibly increased plasma-azapropazone


                                                                                46
                           concentration
                           Inhibition of benzodiazepine metabolism (increased
Benzodiazepines
                           plasma concentration)
                           Metabolism of calcium-channel blockers possibly
Calcium-channel Blockers
                           inhibited (increased plasma concentration)
                           Metabolism of carbamazepine inhibited
Carbamazepine              (increased plasma-carbamazepine
                           concentration)
Chloroquine and            Inhibition of chloroquine metabolism (increased
Hydroxychloroquine         plasma concentration)
                           Cimetidine possibly enhances effects of
Chlorpromazine
                           chlorpromazine
                           Possibly increased plasma-ciclosporin
Ciclosporin
                           concentration
                           Inhibition of clomethiazole metabolism (increased
Clomethiazole
                           plasma concentration)
Clozapine                  Cimetidine possibly enhances effect of clozapine
                           Enhanced anticoagulant effect (inhibition of
Coumarins
                           metabolism)
                           Plasma concentration of doxepin increased
Doxepin
                           (inhibition of metabolism)
                           Increased plasma-erythromycin concentration
Erythromycin
                           (increased risk of toxicity, including deafness)
                           Metabolism of flecainide inhibited (increased
Flecainide
                           plasma-flecainide concentration)
                           Metabolism of fluorouracil inhibited (increased
Fluorouracil
                           plasma-fluorouracil concentration)
                           Plasma concentration of imipramine increased
Imipramine
                           (inhibition of metabolism)
Labetalol                  Increased plasma-labetalol concentration
                           Increased plasma concentration of lidocaine
Lidocaine (lignocaine)
                           (increased risk of toxicity)
                           Manufacturer advises possibility of increased
Loratadine
                           plasma-loratadine concentration
                           Metabolism of mebendazole possibly inhibited
Mebendazole
                           (increased plasma concentration)
                           Renal excretion of metformin inhibited; increased
Metformin
                           plasma-metformin concentration
Metoprolol                 Increased plasma-metoprolol concentration
                           Metabolism of metronidazole inhibited (increased
Metronidazole
                           plasma-metronidazole concentration)



                                                                           47
                        Metabolism of moclobemide inhibited (increased
Moclobemide
                        plasma concentration - halve dose of moclobemide)
                        Plasma concentration of nortriptyline increased
Nortriptyline
                        (inhibition of metabolism)
Octreotide              Absorption of cimetidine possibly delayed
                        Metabolism of opioid analgesic inhibited (increased
Opioid Analgesics
                        plasma concentration)
                        Metabolism of pethidine inhibited (increased plasma
Pethidine
                        concentration)
                        Metabolism of phenytoin inhibited (increased
Phenytoin
                        plasma concentration)
                        Cimetidine inhibits excretion of pramipexole
Pramipexole
                        (increased plasma-pramipexole concentration)
                        Increased plasma concentration of
Procainamide
                        procainamide
Propafenone             Increased plasma concentration of propafenone
Propranolol             Increased plasma-propranolol concentration
Quinidine               Increased plasma concentration of quinidine
                        Metabolism of quinine inhibited (increased plasma
Quinine
                        concentration)
                        Accelerated metabolism of cimetidine (reduced
Rifampicin
                        plasma-cimetidine concentration)
                        Plasma concentration of sertraline increased by
Sertraline
                        cimetidine
                        Cimetidine increases plasma-sildenafil
Sildenafil
                        concentration (reduce initial dose of sildenafil)
Sulphonylureas          Enhanced hypoglycaemic effect
Terbinafine             Increased plasma-terbinafine concentration
                        Metabolism of theophylline inhibited (plasma-
Theophylline
                        theophylline concentration increased)
                        Metabolism of valproate inhibited (increased
Valproate
                        plasma concentration)
                        Plasma concentration of zalcitabine possibly
Zalcitabine
                        increased
                        Metabolism of zaleplon inhibited (increased plasma
Zaleplon
                        concentrations)
                        Cimetidine inhibits metabolism of zolmitriptan
Zolmitriptan
                        (reduce dose of zolmitriptan)

Ranitidine belongs to Histamine H2-antagonists and has the following
interactions information:


                                                                         48
Saquinavir                  Plasma concentration of saquinavir increased


Chelates and complexes have the following specific drug
interactions Tripotassium Dicitratobismuthate :

Tetracyclines                Reduced absorption of tetracyclines
Sucralfate :
Cardiac Glycosides           Possibly reduced absorption of cardiac glycosides
Ciprofloxacin                Reduced absorption of ciprofloxacin
                             Possibly reduced absorption (reduced
Coumarins
                             anticoagulant effect)
Ketoconazole                 Reduced absorption of ketoconazole
Lansoprazole                 Absorption of lansoprazole possibly reduced
Levofloxacin                 Reduced absorption of levofloxain
Levothyroxine (thyroxine)    Reduced absorption of levothyroxine
Norfloxacin                  Reduced absorption of norfloxacin
Ofloxacin                    Reduced absorption of ofloxacin
Phenytoin                    Reduced absorption of phenytoin
Sulpiride                    Reduced absorption of sulpiride
Tetracyclines                Reduced absorption of tetracyclines

Prostaglandins has the following specific interactions:
Oxytocin                     Uterotonic effect potentiated
Proton Pump Inhibitors has the following specific interactions:
                            Plasma concentration of digoxin possibly slightly
Digoxin
                            increased
Itraconazole                Reduced absorption of itraconazole
Ketoconazole                Reduced absorption of ketoconazole




Esomeprazole :
                            Possible inhibition of diazepam metabolism
Diazepam
                            (increased plasma concentration)
Phenytoin                   Effect of phenytoin enhanced
Omeprazole :
Coumarins                   Anticoagulant effect possibly enhanced



                                                                                 49
                              Possible inhibition of diazepam metabolism
Diazepam
                              (increased plasma concentration)
Phenytoin                     Effect of phenytoin possibly enhanced
Tacrolimus                    Possibly increased plasma-tacrolimus concentration
Lansoprazole :
Antacids                     Possibly reduced absorption of lansoprazole
                             Manufacturer advises lansoprazole possibly
Oestrogens
                             accelerates metabolism of oral contraceptive
                             Manufacturer advises lansoprazole possibly
Progestogens
                             accelerates metabolism of oral contraceptives
Sucralfate                   Absorption of lansoprazole possibly reduced
Pantoprazole and Rabeprazole belongs to Proton Pump Inhibitors but has no additional
interactions information.




                                                                                   50

				
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