EXERCISE 6
CASE STUDY ON PEPTIC ULCER DISEASE
Gastrointestinal disorders include such conditions as constipation, irritable bowel syndrome,
hemorrhoids, anal fissures, perianal abscesses, anal fistulas, perianal infections, diverticular
diseases, colitis, colon polyps and cancer. Many of these can be prevented or minimized by
maintaining a healthy lifestyle, practicing good bowel habits and submitting to cancer screening.
OBJECTIVES: At the end of this exercise, the students should be able to:
1. Formulate therapeutic endpoints based on the initiation of a pharmacotherapy plan used to
treat the disease symptoms.
2. Identify appropriate dosage form selection based on the patient’s age, ability to take
medication, or adherence to technique.
3. Determine an appropriate home pharmacotherapy plan, including discharge counseling, as
the patient nears discharge from a hospital setting.
4. Explain the rationale of patient drug therapy and provide appropriate patient counseling for
drug regimens.
PROCEDURE:
1. Read and analyze the cases given.
2. Prepare a complete patient therapeutic plan for each case and a counseling session.
Case 1
William Smith is a 62-year-old man who presents to the emergency department on Sunday
evening complaining of intermittent burning Epigastric pain for more than 2 months. His pain is
non-radiating and occurs to the right of his epigastrium. This pain changes intensity and is
worse with meals. He also noticed intermittent belching, being bloated, being weak when
walking, and complaining of nausea after eating. Since last Friday, he has been having black,
tarry bowel movements. He does not have any history of PUD or GI bleeding and has not
experienced anorexia or vomiting.
PATIENT THERAPEUTIC CARE PLAN RECORD
Patient Name: William Smith Gender: Male
Address: N/A Age: 62 y/o
Birthdate: Year 1959
Medical Condition: Peptic Ulcer Race: N/A
Tobacco/Alcohol/Substance Use: none Weight: N/A
Allergies: N/A Height: N/A
MEDICATION RECORD
Drug Name Indication Strength Regimen Adverse Drug
Reactions
Metformin Type 2 Diabetes 500 mg twice At first, 500 Nausea,
daily milligrams (mg) vomiting,
-Decrease
two times a day diarrhea, vitamin
stomach acidity
taken with the B12 deficiency,
and ulcer index
morning and chest discomfort,
evening meals, abdominal pain,
or 850 mg a day constipation
taken with the
morning meal.
Your doctor may
increase your
dose if needed
until your blood
sugar is
controlled.
Maalox Heartburn, acid 1 tablespoonful Two to four Diarrhea,
indigestion, sour PRN stomach teaspoonfuls constipation,
stomach, upset pain (10-20 mL) four hypermagnesemi
stomach. times a day a,
taken 20 minute hyperaluminemia,
to 1 hour after hypophosphatemi
meals and at a
bedtime or as
directed by the
physician. May
be followed with
milk or water.
Aluminum To relieve 300-600 mg 300-600 mg Nausea,
Hydroxide heartburn, acid TID orally 3 Vomiting,
indigestion, and times/day Rebound
upset stomach. between meals hyperacidity,
They may be and at bedtime. aluminum
used to treat intoxication, low
these symptoms blood phosphate
in patients with
peptic ulcer,
gastritis,
esophagitis,
hiatal hernia, or
too much acid in
the stomach
(gastric
hyperacidity).
Pantoprazole Maintenance of 40 mg twice a Treatment: 40 Headache,
healing of EE and day mg orally once a nausea, vomiting,
reduction in day joint pain,
relapse rates of diarrhea,
-Duration of
daytime and dizziness.
therapy: 8 weeks
nighttime
heartburn -If patients are
symptoms in not healed after
adult patients 8 weeks or
with GERD. erosive
esophagitis (EE)
recurs with the
oral formulation,
treatment for
another 8 weeks
may be
considered.
-Controlled
studies using the
oral formulation
for maintenance
did not extend
beyond 12
months.
Medical Condition Drug-Therapy Goal, Current Status Follow-up Plan
Problem and Interventions
Peptic Ulcer Metformin and The goal is to stop The patient needs to
Aluminum Hydroxide nausea from the have follow-up visits
have an adverse patient. With this the to his doctor. Most
effect that causes patient needs to stop stomach ulcers take
nausea, vomiting, taking Metformin, a few months to heal
diarrhea, the patient wherein Metformin after treatment.
mentioned that he has a direct anti- However, stomach
experienced nausea inflammatory action ulcers can come
after eating. So this that causes nausea. back after treatment,
is contraindicated to Currently, the most although this is less
the patient commonly used likely to happen if the
therapy for peptic underlying cause is
ulcers is a addressed.
combination of
antibiotics, proton
pump inhibitors, and
bismuth salts that
suppress or eradicate
the infection. Stress
reduction and rest.
PATIENT COUNSELLING
● Lifestyle adjustment. It is possible to lessen ulcer irritation by limiting or eliminating
alcohol and smoking from your life.
● Avoid tobacco products.
● Wash your hands frequently and eat foods that have been completely cooked to
avoid getting sick.
● Avoid or minimize NSAID use; acetaminophen or nonacetylated salicylates may be
suitable alternatives.
● Inquire about dietary restrictions to your dietician.
● Follow the instructions given by your prescriber.
Answer the following questions and cite your references.
1. Identify this patient’s drug therapy problems.
Unnecessary Drug Therapy - when only single-pharmacological therapy is acceptable,
several drug products are utilized. It's also possible that the medical condition is caused
by weekly alcohol use or smoking.
Dosage is too high - or the patient's treatment is taking too long - or a medication
interaction is causing a hazardous reaction to the therapeutic product. As an example,
combining large doses of aspirin and ibuprofen.
Adverse drug reaction - occurs when a drug product creates an unwanted side effect
that is not dosage related, or when a safer medicine is required due to patient risk
factors, or when a drug interaction causes an unfavorable side effect that is not dose
related.
2. What are your treatment goals for treating this patient’s PUD?
● Relieve symptoms
● Heal lesions
● Prevent recurrences
● Prevent complications
3. Considering the patient’s presentation, what nonpharmacologic alternatives are
available to treat his PUD?
● Patients with PUD should eliminate or reduce psychological stress, cigarette smoking,
and the use of nonselective NSAIDs (including aspirin). Although there is no need for a
special diet, patients should avoid foods and beverages that cause dyspepsia or
exacerbate ulcer symptoms (e.g., spicy foods, caffeine, alcohol).
4. Based on the patient’s presentation and the current medical assessment, design a
pharmacotherapeutic regimen to treat his gastric ulcer, anemia, and osteoarthritis.
Gastric ulcer Peptic ulcer disease can be treated
medically with antacids, histamine2
receptor antagonists, omeprazole,
prostaglandin analogues, and sucralfate
and bismuth formulations, among other
things. After four to eight weeks of
treatment, 70% to 90% of peptic duodenal
and gastric ulcers will heal.
Anemia Oral delivery of ferrous iron salts is the
most cost-effective and efficient medical
treatment for iron deficiency anemia.
Ferrous sulfate is the most often utilized
of the several iron salts. Other iron salts, it
is said, are better absorbed and have less
morbidity.
Osteoarthritis Acetaminophen is one of the
pharmacologic medications used in the
treatment of osteoarthritis. Calcium
channel blocker/COX-2 inhibitor
combination of oral and topical
nonsteroidal anti-inflammatory
medications (NSAIDs), such as diclofenac
topical.
5. What information should be provided to the patient to ensure successful therapy,
enhance compliance, and minimize adverse effects?
Switching pain medicines is a good idea. Whether you use pain medicines on a regular
basis, check with your doctor to see if acetaminophen (Tylenol, etc.) is a choice for you.
Reduce your stress levels. The signs and symptoms of a peptic ulcer might be made
worse by stress. Consider the reasons for your stress and do everything you can to
eliminate them. Although some stress is inescapable, you may learn to manage it by
exercising, socializing, or writing in a diary.
Smoking is prohibited. Smoking can harm the stomach's protective lining, increasing the
risk of an ulcer developing. Stomach acid is also increased by smoking.
Alcohol should be used in moderation or completely avoided. Alcohol abuse can irritate
and destroy the mucous lining of your stomach and intestines, leading to inflammation
and bleeding.
REFERENCES:
Peptic Ulcer Disease Overview. American Gastroenterological Association. Available online at
https./www.gastro.org/practice-guidancelgi-patient-center/topic/pepticC-ulcer-disease. Accessed
September 2019.
Harris, C. (2016) Peptic Ulcer Disease (PUD) Retrieved from
https://slideplayer.com/slide/8877817/
Peptic Ulcer Disease Treatment (n.d.) Retrieved from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/peptic-ulcer-disease-
treatment
Peptic Ulcer Disease-an Overview American College of Gastroenterology. Available online at
https://gi org/topics/peptic-ulcer-disease! Accessed September 2019
Hunterdon Gastroenterology Associates (2016).Causes, Treatment, prevention of peptic Ulcer.
Retrieved from https://hunterdongastro.com/peptic-ulcers/
Case 2
Patient’s medical history includes COPD x 10 years, Type 2 DM x 10 years, and Osteoarthritis x
15 years in the right shoulder. His father died at age 55 of an acute MI and his mother died at
age 66 from lung CA. He has three siblings who are alive and well. Presently employed as an
account. He is married and has three daughters. He still smokes a cigar occasionally despite his
COPD, and he drinks a case of beer per week.
PATIENT THERAPEUTIC CARE PLAN RECORD
Patient Name: N/A Gender: Male
Address: N/A Age: N/A
Birthdate: N/A
Medical Condition: COPD Race: N/A
Tobacco/Alcohol/Substance Use: Smoking Weight: N/A
and drinking beer
Allergies: N/A Height: N/A
MEDICATION RECORD
Drug Name Indication Strength Regimen Adverse Drug
Reactions
Metformin Type 2 Diabetes 500 mg twice At first, 500 Nausea,
daily milligrams (mg) vomiting,
two times a day diarrhea, vitamin
taken with the B12 deficiency,
morning and chest discomfort,
evening meals, abdominal pain,
or 850 mg a day constipation
taken with the
morning meal.
Your doctor may
increase your
dose if needed
until your blood
sugar is
controlled.
EC Aspirin use for long-term 325 mg Once Drink a full glass Ringing in your
conditions, such daily of water with ears, confusion,
as arthritis and each dose and hallucinations,
migraine take 4 to 8 rapid breathing,
tablets every 4 seizure ; severe
reducing the risk
hours not to nausea, vomiting,
of cardiovascular
exceed 48 or stomach pain;
events
tablets in 24 bloody or tarry
hours unless stools, coughing
directed by a up blood or vomit
doctor. that looks like
coffee grounds;
fever lasting
longer than 3
days.
Ipratropium 2 puffs 4 times 672 mcg/day Dizziness,
MDI daily intranasally; nausea,
FDA-approved heartburn,
labeling for constipation, dry
inhaler mouth, pain when
recommends not urinating.
exceeding 12
puffs/day (204
mcg/day); FDA-
approved
labeling for
nebulizer
solution for oral
inhalation
recommends not
exceeding 4
doses/day or
2,000 mcg/day
(0.02% nebulizer
solution). While
higher doses
have been
reported in trials,
no advantage of
nebulized doses
greater than
2,000 mcg/day in
adults has been
noted.
Albuterol MDI 2 puffs as need Two puffs taken Nervousness or
15 to 30 minutes shakiness,
before exercise. headache, throat
or nasal irritation,
and muscle
aches and
tachycardia.
ASSESSMENT, PLAN AND FOLLOW-UP EVALUATION
Medical Condition Drug-Therapy Goal, Current Status Follow-up Plan
Problem and Interventions
COPD He still smokes a ● reduction of Additional follow-up
cigar occasionally airflow recommendations
despite his COPD, obstruction, are as follows:
and he drinks a case prevention or Patients with severe
of beer per week. management or unstable disease
of should be seen
complications, monthly. When their
and condition is stable,
improvement patients may be seen
in the patient's biannually. Check
quality of life. theophylline level
● Give up with each dose
smoking. adjustment, when
● Eat right and interacting
exercise medications are
● Get rest added, and routinely
● Take your every 6-12 months.
medications
correctly
● Use oxygen
appropriately
● Retrain your
breathing
● Avoid
infections
● Learn
techniques to
bring up
mucus
● Make and use
an action plan
● Learn more
about COPD
PATIENT COUNSELLING
● Change your lifestyle. Eat healthy foods and do physical activities regularly.
● Reduce stress
● Limit alcohol
● Take medication correctly
● Inquire about dietary restrictions to your dietician.
● Follow the instructions given by your prescriber.
Answer the following questions and cite your references.
6. Identify this patient’s drug therapy problems.
● The most prevalent risk factors for PUD are NSAIDs like ibuprofen and aspirin.
The mucosa is injured as a result of the topical use of NSAIDs. When discovered
in the acid environment of the stomach, aspirin and many other NSAIDs are
weak acids that persist in a nonionized lipophilic state. NSAIDs travel through the
lipid membranes of epithelial cells under these circumstances causing cell
damage once trapped intracellularly in an ionized state. Topical NSAIDs can also
change the surface mucous layer, allowing H+ and pepsin to diffuse back into the
epithelial cells, causing additional epithelial cell injury. Furthermore, enteric-
coated or buffered formulations have been linked to an increased risk of peptic
ulcer. Ibuprofen and aspirin should not be used combined to avoid severe
adverse effects, which William Smith did not experience. Patients should not take
two NSAIDs and should take drugs after eating to reduce the risk of nonsteroidal-
related GI side effects; if the risk is considerable, patients should take a
gastroprotective treatment, such as a proton pump inhibitor. Furthermore,
combining metformin with ibuprofen or other anti-inflammatory medications may
increase the risk of lactic acidosis, a rare but serious and potentially fatal
condition caused by an accumulation of lactic acid in the blood that can occur
during treatment with metformin-containing products.
7. What are your treatment goals for treating this patient’s PUD?
● The basic treatment for NSAIDs-induced illness is therapy or prevention.
Treatment of a current ulcer and primary prevention of future harm are two
medical interventions for NSAID-related mucosal injury. The harmful substance
should be discontinued as soon as possible in the treatment of an active NSAID-
induced ulcer. If this is not possible, one of the acid inhibitory drugs (H2 blockers,
PPIs) should be used because of the patient’s severe underlying condition,
stopping NSAIDs is not always practicable.Whether or not NSAIDs are removed,
only PPIs can mend GUs or DUs.
● To prevent NSAID-induced damage, key preventative strategies have included
avoiding the agent, using the lowest possible dose of the agent, utilizing NSAIDs
that are theoretically less harmful, employing newer topical NSAID formulations
and/or concurrent medical care. Misoprostol (200 mg qid) or a PPI can be used
as a first line treatment for NSAID-induced ulcers. Although PPIs are preferable,
high dose H 2 blockers (famotidine, 40 mg bid) have shown some potential in
avoiding endoscopically verified ulcers. Individuals on aspirin prophylaxis must
use gastric protective treatment
8. Considering the patient’s presentation, what nonpharmacologic alternatives are
available to treat his PUD?
● Bleeding, perforation, and stomach outlet blockage are all possible
consequences of PUD, regardless of the cause. The most common consequence
is hemorrhage, with up to 15% of patients reporting some level of bleeding
profusely. For individuals with gastrointestinal bleeds, endoscopy is regarded as
standard of care, and it may be possible to treat the ulcer at the same time.
9. Based on the patient’s presentation and the current medical assessment, design a
pharmacotherapeutic regimen to treat his gastric ulcer, anemia, and osteoarthritis.
Gastric ulcer Peptic ulcer disease can be treated
medically with antacids, histamine2
receptor antagonists, omeprazole,
prostaglandin analogues, and sucralfate
and bismuth formulations, among other
things. After four to eight weeks of
treatment, 70% to 90% of peptic duodenal
and gastric ulcers will heal.
Anemia Oral delivery of ferrous iron salts is the
most cost-effective and efficient medical
treatment for iron deficiency anemia.
Ferrous sulfate is the most often utilized
of the several iron salts. Other iron salts, it
is said, are better absorbed and have less
morbidity.
Osteoarthritis Acetaminophen is one of the
pharmacologic medications used in the
treatment of osteoarthritis. Calcium
channel blocker/COX-2 inhibitor
combination of oral and topical
nonsteroidal anti-inflammatory
medications (NSAIDs), such as diclofenac
topical.
10. What information should be provided to the patient to ensure successful therapy,
enhance compliance, and minimize adverse effects?
○ Understand each patient’s medication-taking behaviors
○ Talk about side effects
○ Write it down
○ Collaborate with patients
○ Consider the financial burden to the patient
○ Assess health literacy
○ Reduce complexity
○ Follow up with patients
○ Engage community pharmacists
○ Use technology
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