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CONTENT UPDATE

Content Update

August 30, 2017

New Recommendations for Use of Proton Pump Inhibitors: The American Gastroenterological Association published an expert review and best practice advice for use of proton pump inhibitors (PPIs) in light of potential adverse effects associated with long-term use. Ten specific recommendations are provided for best practice advice. These articles provide information to assist health care providers assess the risks and benefits of long-term PPI therapy.

PATIENT CARE PROCESS

Patient Care Process for Peptic Ulcer Disease

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Collect

  • Patient characteristics (e.g., age, sex, pregnant)

  • Patient medical history (personal and family) especially prior history of H. pylori infection, previous peptic ulcers, or previous upper GI disorders (see Table 33-4).

  • Social history (e.g., tobacco and ethanol use), as well as recent medical procedures and stress levels (see Table 33-2)

  • Current medications, especially NSAIDs (nonprescription and prescription) nonprescription use of proton pump inhibitors (PPIs), other nonprescription or prescription acid reflux treatments, anticoagulants, and antiplatelet medications. If prior NSAID use, note medication, dosage, and duration of use.

  • Pain: presence or absence, rating (1-10), quality, and location (see Table 33-5).

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight, O2-saturation

    • Laboratory tests, including hemoglobin (Hgb), hematocrit, gastric acid secretory studies, and stool hemoccult

    • Urea breath test (UBT) for detection of H. pylori. Follow-up culture with endoscopy recommended (see Table 33-6)

    • Imaging studies: Upper endoscopy

Assess

  • Hemodynamic stability (e.g., systolic BP>90 mm Hg, HR>110 bpm, O2 sat<90%)

  • Presence of active gastric bleeding based on imaging studies

  • Presence of GI-bleed provoking factors (low platelets, anticoagulant/antiplatelet use, NSAID use, age >65, recent surgery, severe co-morbidities e.g., cardiovascular disease) (see Table 33-4)

  • Presence/absence of H. pylori

  • Emotional status (e.g., anxiety, depression, stress levels)

  • Ability/willingness to pay for ulcer treatment options

  • Ability/willingness to discontinue NSAIDs and switch to another pain reliever, if applicable

  • Ability/willingness to obtain laboratory monitoring tests (e.g., H. pylori status to confirm eradication) (see Table 33-7)

  • Ability/willingness to follow a multiple drug regimen for 10-14 days, with some doses to be taken at specific times

Plan

  • Drug therapy regimen based on ulcer classification and patient’s antibiotic tolerance (e.g., penicillin allergy) (see Table 33-8, 33-9)

  • Patient education (e.g., purpose of treatment, dietary and lifestyle modification, drug-specific information, medication administration)

  • Self-monitoring for resolution of symptoms such as epigastric pain, dyspepsia, when to seek emergency medical attention

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up (endoscopic H. pylori culture, laboratory tests: CBC, serum electrolytes, renal/liver function; see Table 33-10)

Follow-up: Monitor and Evaluate

  • Resolution of PUD symptoms such as epigastric pain and dyspepsia

  • Presence of adverse effects, e.g., N/V/D (PPIs, H2RAs, metronidazole, other antibiotics), headaches (PPIs and H2RAs)

  • Patient adherence to treatment plan using multiple sources of information

  • Monitor patient for symptoms of PUD recurrence, especially if their risk factors change

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