H2 Blockers

1
H2 Blockers

• Not recommended for PUD, OTC strength is too low
• Okay for GERD, will not heal esophageal ulcers,
  recommended for only 2 weeks, if failure ? refer
  to MD
  
• Products
• Zantac (ranitidine), Pepcid (famotidine), Tagamet
  (cimetidine), Axid (nizatidine)
  
• Pepcid and Axid have lowest amts of drug
  interactions
  
• Tagamet can cause gynecomastia, impotence in men
• Pepcid most potent, followed by Axid, Zantac,
  Tagamet
  
• Refer to chart in book

2
Peptic Ulcer Disease (PUD)

• What is it?
• Group of chronic disorders characterized by
  ulcerating mucosal lesions in upper GI tract
  
• chronic inflammatory condition
• common forms are duodenal and gastric ulceration
• Where does it occur?
• Stomach, duodenum
• What causes PUD?
• H. pylori or drug induced (most commonly by
  chronic NSAID use)

3
Drugs that can cause PUD

• methotrexate
• cyclophosphamide
• azathioprine
• erythromycin
• iron
• corticosteriods
• potassium chloride
• NSAIDS

4
Signs and Symptoms of PUD

• Can be symptomatic
• anorexia, nausea, vomiting, belching, bloating,
  heartburn, epigastric pain (pain in the upper
  abdomen)
  
• awakened at night (usu. around 3am, WHY?)
• duodenal ulcers
• epigastric pain, tenderness, burning, gnawing,
  aching between xiphoid process and belly button
  
• relieved with food intake or antacids
• gastric ulcer
• diffuse pain over midepigastrium (midstomach)
• worsened by food

5
Signs and Symptoms, cont.

• Can also be asymptomatic
• silent ulcer
• associated with chronic NSAID use

6
Signs and Symptoms in the elderly

• Usually asymptomatic
• If the patient has symptoms, different from
  before
  
• vague abdominal discomfort, weakness, dizziness,
  anorexia, severe weight loss
  
• usually NOT epigastric pain
• All of these symptoms require a referral to a
  physician (in all age groups, not just elderly)

7
Complications of PUD

• Bleeding
• vomited blood or black material that looks like
  coffee grounds
  
• red blood in stool usu. indicates hemorrhoids
• if stool black or tarry, foul smelling, usu.
  doesnt involve the rectum area ? PUD
  
• the elderly can bleed w/o any prior symptoms
• Perforation, penetration and gastric outlet
  obstruction are also complications of PUD
  

8
Treatment of PUD

• Physician must diagnose PUD before pharmacist can
  recommend treatment
  
• a pharmacists role in PUD is
• referral to physician
• helping to select an antacid as adjuvant therapy
  to reduce pain (only when advised by a
  physician)
  
• evaluating patient after 2 weeks of therapy
  (prescription and nonprescription meds)
  

9
Pharmacologic Therapy

• Remember OTC meds for PUD are only recommended
  after PUD is diagnosed and the MD wants pt on an
  OTC adjuvant therapy
  
• Bismuth subsalicylate (BSS)
• MOA suppress H. pylori, cytoprotection
• ADRs neurotox assoc. with the subnitrate and
  subgallate salts (rarely used), black
  stool/tongue (hard to distinguish between
  black/tarry stool seem in GI bleeding), follow
  MDs recommended dosage
• Remember to question elderly population when they
  seek bismuth (asymptomatic) ? referral

10
Pharmacologic Therapy, cont.

• Antacids
• Covered by Jon
• For PUD, need around 80 to 160 mEq ANC
  (acid-neutralization capacity) w/ no adjuvant
  therapy 1-3 hours after meals and qHS
  
• with adjuvant therapy, around 40-80 mEq ANC PRN
• Usu. only need supplemental antacids for first
  7-14 days of treatment for PUD
  
• Refer to chart in OTC book for ANC/drug
  interactions