How to prevent peptic ulcer?

Gastrointestinal ulcers are acute lesions on the mucosal surface of the gastrointestinal tract, which may occur in critically ill patients or in stressful events due to major psychological trauma, surgery or trauma. injury... or drug use. So how to prevent peptic ulcer?

Stress-induced peptic ulcers usually occur at the fundus and body of the stomach, but sometimes peptic ulcers also develop in the antrum, duodenum, and distal esophagus. Stress-induced peptic ulcers are usually superficial ulcers that bleed from the capillaries at the surface of the gastrointestinal mucosa. In some severe cases, there will be deeper lesions that erode the submucosa, causing heavy bleeding or perforation of the stomach and duodenum.
The harmful effects of gastrointestinal ulcers caused by stress are great. The rate of patients dying from ulcers occurring in the gastrointestinal tract with bleeding complications is up to 50% and prolonging the average hospital stay from 4 to 8 days, increasing the cost of treatment.
Stress-induced peptic ulcer is the most common occurrence in patients treated in the ICU. Endoscopic evidence shows that 1 to 2 days after the patient is admitted to the ICU, peptic ulcer due to stress will appear in most patients (76% - 100%), this is one of the causes of the disease. aggravation and increased mortality in ICU patients.

For the prevention of peptic ulcers caused by stress, the main drugs recommended include histamine H2 receptor antagonists and proton pump inhibitors (PPIs). Among them, proton pump inhibitors are the most widely used drugs today.
However, many studies show that PPIs are overused and often inappropriately prescribed. The rate of inappropriate use of PPIs for prophylactic purposes ranges from 50-70% in terms of indications, doses, routes of administration and duration of prophylaxis. Inadequate prophylaxis increases the cost burden and increases the risk of drug side effects.
To date, in the world, there is only guideline for prevention of peptic ulcers due to stress of the American Society of Health Care Pharmacists (ASHP) in 1999, which fully recommends indications and prophylactic strategies. Prevention of peptic ulcers caused by stress. Accordingly, PPI prevention of stress-induced peptic ulcers is only recommended for ICU patients with risk factors. There are no recommendations for prevention of stress-induced peptic ulcers in general inpatients. Patients are prescribed PPIs for the prophylaxis of peptic ulcers due to stress when the patient has at least one risk factor:
Respiratory failure: patients on mechanical ventilation for more than 48 hours; Coagulation disorders: Platelet count < 50,000 cells/mm3 or aPTT time > 2 times the control number or INR value > 1.5; History of ulceration or gastrointestinal bleeding within 1 year prior to admission; Traumatic brain injury Glasgow score ≤ 10; Patients with multiple trauma with ISS score ≥ 16; Burn damage > 35% body surface area; Partial liver resection; Spinal cord injury; Transplant; Liver failure; At least 02 of the following factors: Sepsis, stay in the intensive care unit for > 1 week, occult gastrointestinal bleeding lasting 6 days or longer, high dose corticosteroid use (over 250mg/day as active ingredient hydrocortisone or equivalent).

Drugs used to prevent stress-induced peptic ulcer are the following drugs:
Cimetidine: oral administration, gastric tube, intravenous injection at a dose of 300mg x 4 times/day or intravenous infusion: 50mg /hour. For people with impaired renal function Clearance Creatinin (Clcr) < 30ml/min, use orally, gastric tube, intravenous dose of 300mg x 2 times/day or intravenous infusion: 25mg/hour; Famotidine: oral administration, gastric tube, intravenous injection at a dose of 20mg x 2 times/day or intravenous infusion: 1.7mg/hour. If Clcr < 30ml/min, use orally, nasogastric tube, intravenous dose 20mg/time/day or intravenous infusion: 0.85mg/hour; Ranitidine: oral administration, gastric tube, intravenous injection at a dose of 150mg x 2 times/day or intravenous infusion: 6.25mg/hour. If Clcr < 50ml/min can be used orally, nasogastric tube at a dose of 150mg 1 or 2 times/day, intravenous dose of 50mg/12-24 hours or intravenous infusion: 2-4mg/hour; Omeprazole: loading dose: 40mg and maintenance dose: 20-40mg/day (oral, gastric tube or intravenous route). There is no need to adjust Omeprazole for patients with impaired renal function; Lansoprazole: used orally, by nasogastric tube or intravenously at a dose of 30mg/day and does not need to be adjusted for people with impaired renal function; Esomeprazole: used orally, by nasogastric tube or intravenously at a dose of 20-40mg/day and does not need to be adjusted for people with impaired renal function; Rabeprazole : used orally or gastric tube at a dose of 20mg / day and does not need to be adjusted for people with impaired renal function; Pantoprazol: used orally, by tube or intravenously at a dose of 40mg/day and does not need to be adjusted for people with impaired renal function; Sucralfate is used at a dose of 1g x 4 times/day (oral or nasogastric) and does not need to be adjusted in patients with impaired renal function.

NSAID is an anti-inflammatory pain reliever that can affect the lining of the stomach and upper gastrointestinal tract of patients, including: peptic ulcer and complicated complications, the most serious can lead to bleeding gastrointestinal bleeding and even gastrointestinal perforation. Up to 25% of patients on long-term NSAID use will develop gastrointestinal ulceration and 2 - 4% gastrointestinal bleeding or perforation. Medical experts recommend that when doctors prescribe patients to use NSAIDs, they should pay attention to the following two issues:
Detect high-risk patients; Select the appropriate treatment regimen for the patient to prevent peptic ulcer and its complications. In addition, the choice of NSAID for patients also needs to consider the ability of the drug to reduce pain, anti-inflammatory and toxicity on the digestive and cardiovascular system in each individual. Accordingly, the risk factors that are likely to cause gastrointestinal complications related to NSAIDs include:
History of gastrointestinal events, especially complications; Age over 65; Patients taking anticoagulants, other NSAIDs including low-dose aspirin or high-dose NSAIDs; Disorders that cause chronic weakness in the body, especially cardiovascular diseases; Low-dose aspirin is also a risk factor for gastrointestinal complications; Infection with the H. pylori bacteria increases the risk of gastrointestinal complications with NSAID use. All patients with a history of peptic ulcers when taking NSAIDs should prioritize testing for H. pylori, if positive for H. pylori, antibiotic therapy should be applied to eradicate.

PPIs have been shown to significantly reduce peptic ulcer disease and its complications in patients taking NSAIDs or COX-2 inhibitors for treatment; Misoprostol at the maximum dose (800 mcg/day) has been shown to be effective in preventing ulcers and ulcer-related complications in patients taking NSAIDs. However, the usefulness of this active substance is limited by the side effects caused on the gastrointestinal tract. When Misoprostol is used at a lower dose, the side effects of Misoprostol are similar to those of PPIs and are similar in efficacy in preventing drug-induced peptic ulcers. According to the drug's mechanism of action, the use of COX-2 inhibitor NSAIDs has a significantly lower incidence of peptic ulcer disease compared with the use of older traditional NSAIDs. However, these beneficial effects of COX-2-inhibitor NSAIDs are significantly reduced when patients take this drug concomitantly with low-dose aspirin. This benefit of COX-2 inhibitor NSAIDs is also reduced because some studies have shown an association between myocardial infarction and other cardiovascular events with the use of COX-2 inhibitors. Therefore, the lowest dose of celecoxib should be used to minimize the risk of cardiovascular events.
Although the use of high-dose H2-antagonists may reduce the risk of peptic ulcer disease at internal diagnosis in patients taking NSAIDs (study compared with placebo). However, H2 antagonists are significantly less effective than PPIs, and there are no clinical data to support the use of H2 antagonists in the prevention of drug-induced peptic ulcers.
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