PUD & COX-2 Inhibitors

[Pharmacie]

Hello !

*-If a patient suffers from Rheumatoid Arthiritis and has prior history of Peptic Ulcer Disease.Is it approperiate to switch the patient from the non selective NSAID that are used in Rheumatoid Arthiritis to a selective Cox-2 Inhibitor.The issue here is the CV safety of selective COX-2 inhibitor in the long term.



*-Can Aspirin 81 mg cause PUD


*-It seems that the antibiotic doses in the PPI-based three drug regimen are high because:
Amoxicillin 1g BID
Clarithromycin 500 BID

that means each day the pateint consumes 3g of antibiotics for 14 days

[Nik]

Technically NSAID's are contra-indicated in pts with a history of peptic ulcer disease, whereas the coxibs aren't. However if NSAID's provide good pain relief can consider co-prescribing a PPI eg omeprazole with a low risk NSAID and make sure patient understands why. If NSAID originally caused the bleed then can continue cautiously with a PPI. Other factors need to be considered though such as CVD risk or history of CVD. Would also need to keep an eye on DMARD's eg methotrexate as most pts get started on one sooner rather than later.
81mg aspirin sounds like a clinical trial dose to me - whether it can cause a peptic ulcer depends on patient factors, eg age, history of bleed etc. If really concerned about potential bleed but aspirin definitely indicated, then could consider low dose PPI, otherwise 75mg aspirin tends to be quite safe.

[johnep]

My wife was prescribed Celebrex. Started GI bleed but could not think it was the Celebrex. Went so far as to have the usual tube pushed up. There was a bleeding point, it wasn't cancer, it was the Celebrex. Now takes Omep 20mg if taking Ibu.
johnep

[grumpy jeff]

81mg is the standard american dose.

[sNASA]

Seems odd after being used to 75mg.

Also, I think I might have the wrong perception about Americans, but do they commonly take aspirin for headaches rather than paracetamol? (It's mostly a tv based opinion though, so half a chance it's probably incorrect.)
Thanks.

[_Rob_]

Seems odd after being used to 75mg.

Also, I think I might have the wrong perception about Americans, but do they commonly take aspirin for headaches rather than paracetamol? (It's mostly a tv based opinion though, so half a chance it's probably incorrect.)
Thanks.

Or do they take Acetaminophen...

[grumpy jeff]

or tylenol...

[_Rob_]

Going back to the original question...

COX2 inhibitors are still a risk for PUD however, the incidence is reduced over the non-selective COX inhibitors. The patient needs to be reviewed as a whole with consideration given to other risk factors such as recent Hx of PUD, other drugs, alcohol intake, BMI etc... just asking if it is appropriate to switch a patient from one to the other is a little basic.

Can 81mg of Aspirin cause PUD - yes any dose of aspirin can be a co-factor in PUD however see comments above because there are many other factors involved in PUD. A pure aspirin/NSAID gastric ulcer is a real rarity. The latest evidence suggests that aspirin/NSAID often cause more erosion of the mid GI tract, past the stomach and duodenum and more into the small intestine. The is why we often see patients with dropping Hb's but on endoscopy/colonoscopy there is NAD.

Antibiotics & triple therapy in H.Pylori erradication regimens - I really don't understand the question and why have you added the dose of Amoxicillin and Clarithromycin together? They are different drugs with different molecular weights and entirely different mechanisms of action.

The dose of antibiotics given is dependent on the MIC required to kill the bacteria causing the problem. The pharmacokinetics of the ABx will also dictate the dose required, for example, you need a much higher dose to treat bone infections or CNS infections than you do for lung infections as the penetration of the antibiotic is less into bones or the brain. A good example of this is oral cephalosporins; when given orally, they are crap at treating chest infections as you cannot give sufficient dose to penetrate the lung tissue without causing severe diarrhoea and abdo pains. However, given IV, the GI tract is circumvented and you can give a sufficent dose to penetrate the lung tissue. (e.g. Cefuroxime Axetil oral = 250mg BD vs IV Cefuroxime upto 1.5g TDS).

[Nik]

I prefer 300mg aspirin over standard dose paracetamol for pain relief as I just find it works better for me.