A peptic (derived from the word pepsin, an enzyme in the stomach that helps digest protein) ulcer is

defined as an erosion in the lining of the stomach, the first part of the small intestine (also known as the duodenum), or esophagus that results in the development of an open lesion. The majority of peptic ulcers occur in the duodenum. Nearly 10% of Americans will suffer from a peptic ulcer at some point in their lives. Many individuals mistakenly believe these ulcers are caused be lifestyle factors such as stress or eating spicy foods. In reality, most peptic ulcers are caused by the presence of a specific bacterium or medications. Today, most ulcers can be prevented or treated using a variety of appropriate therapies.

SymptomSSmall ulcers typically go unnoticed because they rarely produce symptoms such as pain or abdominal discomfort. However, some ulcers may result in serious bleeding or even perforation, thus their severity must not be underestimated. An ulcer can be defined as a hole or tear in the wall of the stomach. The hallmark symptom of ulcer disease is a burning or gnawing sensation that produces abdominal pain. Other common symptoms include heartburn, nausea and vomiting. Those with a family history of ulcers, individuals 50 years of age and older and those suffering from liver, kidney or lung disease are more likely to develop this condition.

Pain associated with ulcers is produced by the local effects of stomach acid on the open or inflamed lesion. The pain frequently occurs during the night and becomes worse when the stomach is empty. Pain can be temporarily relieved by eating foods that serve to buffer the stomach acid or by taking medications that reduce acid production. Over-the-counter antacids and acid blockers may offer short-term relief; however, prolonged ulcer-type pain MUST be brought to the attention of a physician.

CauSeSMost cases of peptic ulcer disease are considered to be due to the effects of a

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peptic ulcer diseAse: Feel the Burn

bacterium known as Helicobacter pylori (H. pylori). The association between this organism and ulcer disease was first made by Marshall and Warren in the early 1980’s and they were recognized in 2005 by being awarded the Nobel Prize in Medicine. H. pylori resides within the mucous layer that protects tissues lining the stomach and small intestine. Although it may be found in nearly 50% of all individuals, H. pylori typically does not result in gastric symptoms. It can, however, disrupt the mucous layer resulting in irritation and ulceration.

Peptic ulcers may also be associated with the regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen (Advil). Smoking and excessive consumption of alcohol may also result in ulcer formation. Although stress itself is not considered a primary cause of peptic ulcers, it can result in their delayed healing.

DiagnoSiSIf you suspect you may be suffering from a peptic ulcer, contact your physician. As discussed earlier, long-standing symptoms may be related to other diseases, including cancer. This is the major reason the maximum recommended duration for treatment of abdominal pain with many over-the-counter preparations is only fourteen days. Your doctor will most likely ask you a number of questions including when you first began to experience discomfort and whether there was anything that routinely improved or worsened your symptoms. Prior to seeing the physician, make a list of all prescription and non-prescription drugs and dietary supplements you are currently taking.

You may require some diagnostic tests to determine the actual presence and location of an ulcer. The procedure of choice for most physicians is known as endoscopy. You will be mildly sedated and the doctor will use an instrument known as an endoscope. This tube-like device permits the gastroenterologist to actually view the esophagus, stomach and upper part of the small intestine. If an ulcer or other lesion is detected, your doctor may elect to remove

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peptic ulcer diseAse: Feel the Burn

Newsletter ContributorsJohn G. lech, pharm.d.Katie A. Garcia, pharm.d.Kevin J. Gillon, pharm.d. candidateleigh A. smyczek, pharm.d. candidate

A publication of:mylan school of pharmacycenter for pharmacy carepharmaceutical information center (pic)

Additional information on newsletter topics: pharmaceutical information center 412-396-4600pic@duq.edu

Questions about screenings or programs:christine O’Neil, pharm.d, b.c.p.s.412-396-6417

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For more information on peptic ulcer disease, please visit the following websites:• www.webmd.com/digestive-disorders/digestive-diseases-peptic-ulcer-disease• www.nlm.nih.gov/medlineplus/pepticulcer.html• www.mayoclinic.com/health/peptic-ulcer/DS00242

w w w . d u q . e d u / p h a r m a c y

a small section of tissue and perform a biopsy. This is an important step because it allows the physician to rule out more serious conditions including cancer.

treatmentOnce the presence of an ulcer has been established, physicians typically use two different methods for treating the condition. If present, many physicians eliminate H. pylori by prescribing various combinations of antibiotics. These include medications such as amoxicillin (Amoxil, etc.), clarithromycin (Biaxin, etc.) and metronidazole (Flagyl). In general, the antibiotics will be prescribed for periods ranging from 10-14 days. The antibiotics will also be prescribed in combination with drugs known as proton-pump inhibitors (PPIs). These drugs are considered the most potent inhibitors of acid secretion and permit more rapid healing of the ulcer(s).

For patients who have an ulcer without evidence of bacterial infection, physicians will most likely prescribe one of the PPIs mentioned above. If this class of drugs is not suitable or does not provide adequate relief, there are alternatives. Another group of drugs that reduces acid production is known as histamine H2- antagonists. Cytoprotective agents are sometimes prescribed to protect the tissues that line the stomach and small intestine. Please see the accompanying table for a list of the various agents now available for treating peptic ulcer disease. It is extremely important that you follow your doctor’s instructions on how to take these medications. You must take them for the

prescribed period of time. Failure to do so may lead to incomplete elimination of the bacteria and continued progression of your condition.

Sometimes ulcers fail to heal even when you are taking medications. Reasons include not taking the medication according to directions, use of alcohol and tobacco, resistance of H. pylori to the antibiotics and continued use of NSAIDs.

What you Can DoYou can take steps to prevent the development of ulcers. Although NSAIDS are effective in reducing pain, excessive use of these medications can lead to ulcer formation. If possible, avoid using drugs

like aspirin, ibuprofen or other NSAIDS for prolonged periods of time. Acetaminophen (Tylenol, etc.) is an effective analgesic and not usually associated with ulcer disease. If you have any questions about what you should be taking for pain management, speak with your doctor or pharmacist. Patients who smoke, chew tobacco and/or drink alcoholic beverages increase their risk of developing an ulcer.

Everyone must be aware of the warning signs and symptoms of ulcer disease and seek medical attention when they become severe and/or chronic. When in doubt, it is always preferable to speak with your physician. In the case of peptic ulcers, it is better to be safe than sorry.

*Many of the drugs in these categories have been reported to interact with prescription and non-prescription drugs. Please check with your doctor or pharmacist before using any of these medications.

Drugs Used in Peptic Ulcer Disease drugclass genericname brandname possibleadverse reactions

protonpumpinhibitors(ppis)*

Histamineantagonists(H2-blockers)*

cyto-protectiveagents

Dexilant

Nexium

Prevacid

PrilosecZegerid

Protonix

Aciphex

Tagamet

Pepcid

Axid

Zantac

Pepto-Bismol

Cytotec

Carafate

dexlansoprazole

esomeprazole

lansoprazole

omeprazole

pantoprazole

rabeprazole

cimetidine

famotidine

nizatidine

ranitidine

bismuth subsalicylate**

misoprostol***

sucralfate

abdominal paindiarrheadizzinesselevated liver enzymesflatulenceheadachenauseapancreatitisrashvomiting

agitationconfusionconstipationdepressiondiarrheadrowsinesshallucinationsheadachenausea rashvomiting

abdominal painblackened tongue**constipationcontraindicated during pregnancy***diarrheaheadachenausearinging of the earsvomiting