Peptic Ulcer Disease
                           ====================
þ H2 receptor antagonists vs. PPI (proton pump inhibitors) for PUD
 - "omeprazole (Prilosec) binds to the proton pump of the parietal cell,
   inhibiting secretion of hydrogen ions into th gastric lumen.  In doses of
   20 to 40 mg/day, it inhibits more than 90% of of 24-hour acid secreation,
   compared with 50% to 80% with standard doses of H2-antagonists.  ...
   Ompeprazole relieves pain and heals peptic ulcers more rapidly than
   H2-antagonists (P Maton, N Engl J Med 324:965, 1990)."

þ Proton Pump Inhibitors (PPIs): equivalent doses
  lansoprazole (Prevacid)       30 mg PO daily          60 mg PO daily
  pantoprazole (Protonix)       40 mg PO daily          80 mg PO daily
  omeprazole (Prilosec)         20 mg PO daily          40 mg PO daily
  rabeprazole (Aciphex)         20 mg PO daily          40 mg PO daily

þ Empiric Treatment of Dyspepsia in ED
  <Ulcer.TXT>

þ Cause of PUD
 - "Most peptic ulcers not caused ny NSAIDs are now thought to be associated
   with infection of the gastric mucosa by the gram-negative bacilli
   Helicobacter pylori (NIH Consensus Development Panel, JAMA, 272:65, July 6,
   1994). NSAID-related ulcers are usually gastric.  H. pylori have been
   associated with both duodenal and gastric ulcers." [Med Ltr
   1994;36(927):65-67.]

þ Diagnosis of H. Pylori infections
 - biopsy
 - breath test
 - ELISA test

þ Effectiveness of PUD treatment
 - "One 12-month controlled trial in patients with duodenal ulcers and
   biopsies positive for H. pylori found that ulcers recurred in 4 of 50
   patients after treatment with an H2-receptor antagonist plus antibiotics,
   compared to 42 of 49 given an H2-receptor antagonist and a placebo (E
   Hentschel et al, N Engl J Med, 328:308, 1993.)  Long-term ulcer recurrence
   rates have also been much lower than usual when H. pylori were eradicated
   (GM Forbes et al, Lancet, 343:258, Jan 29, 1994)."

þ Choice of Drugs for PUD
 - Pepto-Bismol (bismuth subsalicylate), TCN, metronidazole, amoxicillin, and
   clarithromycin, usually 2 or 3 together with an antisecretory drug.
 - However, "one controlled trial found that concurrent use of amoxicillin,
   500 mg QID with omeprazole, 20 mg BID for two weeks was about as effective
   as bismuth subsalicylate, tetracycline, metronidazole and ranitidine, with
   a lower incidence of adverse effects (J Labenz et al, Gut, 34:1167, 1993.)
   Use of clarithromycin with omeprazole has also been effective (RPH Logan et
   al, Gut, 35:323, 1994)."

   Amox 500 QID ($17.34)+ omeprazole (Prilosec) 20 BID ($222.46) for 2 wks
   or
   Clarithromycin 500 mg TID ($120.13) + omeprazole 20 BID ($222.46) for 2 wks

þ Misprostol (Cytotec) for PUD
 - effective for preventing PUD from NSAIDs
 - main side effect is diarrhea (in about 25% of those taking 100 ug QID)
 - will cause abortion if taken by a pregnant woman.
 - " ...100 ug is better tolerated [than 200 ug] and almost as effective."
 - 100 ug QID is statistically less protective than 200 ug QID but still
   better than placebo and has fewer side effects.
 - 100 200 ug tablets cost about $50 (1995)
 - Misoprostol is also as effective as antacid titration for prevention of
   stress ulceration in the ICU. [Ann Surg 210(5):1590,1989]

(prices and quotes from Med Ltr article cited at top)