Prescribing Notes

Peptic ulcer, Z-E syndrome

Non-pharmacological intervention Lifestyle changes may help to relieve symptoms. NSAIDs should be avoided, obese patients should lose weight, smoking should be discouraged.

Pharmacological intervention Treatment should be individually tailored and aimed at symptom relief, healing and prevention of complications or recurrence of disease. Where Helicobacter pylori might be implicated, therapy should include the means to eradicate it.

H2 antagonists reduce basal, nocturnal and stimulated acid secretion. They are rapidly and well absorbed after multiple or single oral doses. Side effects are generally rare and minor, but dosage should be reduced in patients with renal impairment. CNS related effects occur more frequently in the elderly and high doses of H2 antagonists can cause gynaecomastia. Cimetidine also impairs the metabolism of concomitant drugs oxidised by the cytochrome P450 system, eg phenytoin, warfarin, theophylline.

Proton pump inhibitors inhibit both basal and stimulated gastric acid secretion. They produce a more rapid response and promote ulcer healing at a faster rate than H2 antagonists, and have a marked advantage over H2 antagonists in terms of symptom response and healing of GORD and reflux oesophagitis. Esomeprazole, omeprazole, lansoprazole or rabeprazole may be used for patients with Zollinger-Ellison syndrome. Proton pump inhibitors are generally well tolerated and dosage adjustment is not necessary in the elderly or patients with liver disease. The most frequently reported adverse effects are diarrhoea, rash and headache.

Cytoprotectants enhance the secretion of protective mucus and bicarbonate and/or provide a physical barrier covering the ulcer. Misoprostol is useful in the treatment and prophylaxis of NSAID-induced gastrointestinal damage. It is rapidly absorbed and is as effective as H2 antagonists in promoting duodenal ulcer healing but is less effective in healing gastric ulcers or relieving reflux oesophagitis. Misoprostol can cause diarrhoea and uterine contractions and is contraindicated in pregnancy or women planning a pregnancy due to the risk of miscarriage.

The anticholinergic glycopyrronium bromide diminishes the volume and free acidity of gastric secretions. It may be used as an add-on in the treatment of peptic ulcer.

H. pylori eradication It is estimated that H. pylori is associated with 95% of cases of duodenal ulcer and 70% of cases of gastric ulcer. Eradication of the organism therefore forms a cornerstone of treatment of these conditions. Most treatment regimens are based on the use of a drug such as a proton pump inhibitor or an H2 antagonists to suppress gastric acid, plus one or more antibiotics (amoxicillin, clarithromycin, metronidazole) to kill the organism. Triple therapy, involving the use of two antibiotics is more effective in eradicating H. pylori infection than dual therapy, involving the use of one antibiotic. Length of treatment, risk of side effects and the cost of dual therapy are less favourable compared with triple therapies. If using metronidazole, consideration needs to be given to bacterial resistance, which is frequently encountered and is an important prognostic factor in determining the success of the eradication regimen. In addition, approximately one third of patients experience adverse events with metronidazole, including life threatening colitis.