A 54-year-old woman was admitted to the hospital after vomiting blood and was found to have a bleeding duodenal ulcer. She received treatment including blood transfusion and endoscopic hemostasis. Testing showed infection with Helicobacter pylori. She is now well and ready for discharge. The doctor needs to prescribe treatment to eradicate H. pylori and prevent ulcer recurrence, as well as restart the patient's usual hypertension medications. A discharge letter will be provided to the general practitioner with details of treatment changes.

1. Case-Based Exercise
Writing Prescription
For
PEPTIC ULCER
Disease
Shivankan Kakkar, MD

2. Prescribing is more than writing a drug order on a chart and requires a subset of
competencies involving knowledge, judgement and skill.
Prescribing is currently undertaken in a complex healthcare environment with
growing numbers of medicines, ageing patients who have increasing numbers of
comorbidities, and dwindling resources.
Studies have highlighted adverse drug effects and prescribing errors as significant
issues.
Prescribing well is difficult. Opportunities to practice as a student are limited, and
looking back many doctors describe an insufficient emphasis on the practical aspects
of prescribing in the undergraduate curriculum.
This lecture is one attempt to help by providing clear, concise guidance on how to
prescribe safely and effectively, and should be used in combination with practical
examples.
2

3. RECALL- Using Drugs for the Gastrointestinal System
3

4. RECALL- Using Drugs for the Gastrointestinal System
4
Areas with low clarithromycin resistance
Standard triple drug therapy
1. Clarithromycin 500 mg q12hrly
2. Amoxicillin 1000 mg q12hrly
(Metronidazole 500 mg if penicillin
allergy)
3. Lansoprazole 30 mg q12hrly
Areas with high clarithromycin resistance
Standard quadruple drug therapy
1. Lansoprazole 30 mg q12hrly
2. Bismuth subcitrate 120 mg q6hrly
3. Tetracycline 500 mg q6hrly
4. Metronidazole 500 mg q8hrly
Treatment of choice H.pylori eradication therapy
For 14 days For 14 days

5. Acid suppression
Dyspepsia is a common symptom. It may be a sign of serious disease so it is important
that the correct diagnosis is made before starting acid suppression therapy.
This means that prescribers should be alert to ‘red flag’ symptoms such as
gastrointestinal bleeding, dysphagia, weight loss, abdominal swelling or persistent
vomiting.
Most dyspepsia is benign, however, caused by gastro-esophageal reflux disease
(GERD), uncomplicated peptic ulcer disease or non-ulcer dyspepsia.
Antacids are widely used and very safe medicines containing magnesium or
aluminium salts, which neutralise gastric acid and raise gastric pH, thereby increasing
gastric emptying.
5

6. Antacids are less effective than other acid suppressants. In general, liquid preparations
are more effective than tablets. Magnesium-containing antacids can cause diarrhoea,
whereas those with aluminium may cause constipation. In patients with liver failure,
the large sodium load may increase ascites and can precipitate constipation, leading to
encephalopathy. Similarly, renal patients may experience fluid retention with
aluminium salts or magnesium toxicity with magnesium salts. Antacids can affect the
absorption of other drugs, so should not be taken at the same time of day.
H2-Antagonists block histamine receptors that promote acid production by gastric
parietal cells in response to gastrin. Ranitidine is the most commonly used agent, but
the use of this class has been superseded by proton pump inhibitors (PPIs), which are
more effective. H2-Antagonists can cause diarrhoea, headache and dizziness
infrequently, and occasionally cause a rash. Cimetidine can cause gynaecomastia and
impotence, as well as interactions via the cytochrome P450 system.
6

7. PPIs have revolutionised the treatment of GERD and peptic ulcer disease. They work
by blocking the proton pump in the gastric parietal cell that moves hydrogen ions into
the gut lumen where it forms hydrochloric acid. They are highly effective, but possibly
overused. As with all treatments, the lowest effective dose should be used for the
shortest possible duration. Higher doses are used for ulcer healing, but can be
reduced after 4 to 8 weeks, depending on the indication.
Interactions with PPIs are partly group effects (i.e. interference with absorption of
other drugs caused by raising stomach pH), but there are some drug-specific effects
(i.e. interactions via cytochrome P450s). In general, omeprazole (and its enantiomer
esomeprazole) has the most commonly seen issues, inhibiting a range of drugs
including clopidogrel, warfarin and phenytoin. Side effects include gastrointestinal
upset and diarrhoea as well as headache. Importantly, use of PPIs is associated with
an increased incidence of Clostridium difficile infection and osteoporotic fractures.
7

8. Case Based Exercise
Case Record Form and Discharge Sheet Template provided to the students.
Summary of the case:- An admitted patient for hematemesis is found
to have a duodenal ulcer as the underlying cause.
Task for the students:- Your patient is ready for discharge.
1. Review her treatment.
2. Prescribe her discharge medication as appropriate.
8

9. Patient name: SM ID number: 100045 Date of birth: 03/03/1966
Age: 54 years Weight: 71 kg
Admission date: 04/01/2021 Date/time seen: 07/01/2021 10:00
Problem Routine review before discharge.
History SM was admitted 3 days ago after vomiting up blood. Over the past 3 months she
has had intermittent epigastric pain relieved by eating and indigestion tablets. Her weight has
been steady and she has had no change in bowel habit. On the day of admission she felt
nauseated for several hours, before vomiting up a large amount of bright red blood and
passing black tarry stools.
On admission to hospital she received a blood transfusion and underwent urgent endoscopy,
at which bleeding from a duodenal ulcer was controlled.
She now feels well with a good appetite and no abdominal discomfort. Her bowel motions are
a normal colour. Her energy levels are good, she has no shortness of breath and she is keen
to get home as soon as possible.
9

10. PMH Pre-eclampsia, hypertension.
DH At admission: amlodipine 5 mg daily, ramipril 5 mg daily (both withheld during the
admission). Started during the admission: 72-hour IV infusion of high-dose omeprazole
completed this morning, cyclizine 50 mg IV/IM 8-hourly as required (last dose 3 days ago).
Drug Allergies: Penicillin.
SH She smokes 10 cigarettes and drinks 60 ml of vodka per day.
Examination
General She looks well. Obs T 36.7°C, HR 72 beats/min, BP 168/96 mmHg, RR
13 breaths/min, SpO2 98% breathing air. Abdo Soft, non-tender.
Investigations
Endoscopy report 04/01/2021: Normal esophagus and stomach. Moderate-sized ulcer in
duodenum, visible vessel in base, injected with adrenaline. Good hemostasis achieved.
Campylobacter-like organism (CLO) test positive for Helicobacter pylori.
10

11. What should I consider when deciding what to prescribe?
Mrs SM is NOW WELL following hospital admission for a bleeding duodenal
ulcer. When planning her discharge medication you need to determine whether she
needs ongoing treatment for her duodenal ulcer to ensure healing and prevent
recurrence. You also need to consider whether prior medicines for her hypertension
should be restarted and whether there could be interactions between old and new
therapies. It is essential that all changes in medication are communicated clearly to Mrs SM
and her GP.
11

12. Consider new diagnoses
Mrs SM was found to have a duodenal ulcer causing hematemesis. She was treated
with adrenaline at endoscopy to achieve haemostasis, followed by a 72-hour infusion
of omeprazole to reduce the risk of rebleeding. Prior to discharge you need to
consider whether any additional treatment is required to promote ulcer healing and
reduce the risk of recurrence. As she was found to have Helicobacter pylori infection
on CLO (rapid urease) test, you should prescribe an H. pylori eradication regimen.
New medicines to start
H. pylori eradication regimens usually include a proton pump inhibitor (PPI) with two
antibiotics, chosen from amoxicillin, clarithromycin and metronidazole. A range of
regimens have been proven to be effective in diverse clinical trials. The regimens may
involve different doses and frequency of administration of the component drugs to
those you would normally use in other indications.
12

13. 13
CASE

14. 14
Exercise

15. 15
Answer Key

16. In Mrs SM’s case you should choose a regimen that does not include amoxicillin as
she is allergic to penicillin.
New medicines to stop
She has not required the anti-emetic drug cyclizine for 3 days. This can now be
stopped.
Anything else?
As Mrs SM has had a large bleed you should consider whether she needs any iron to
allow her to replenish her red blood cells. At present she has no symptoms of anemia
and her hemoglobin concentration is in the normal range, so this is not necessary.
The lifespan of transfused red cells is less than that of native red cells, so you might
suggest to her that if she develops fatigue or shortness of breath in coming weeks
she should see her GP to check she has not become anemic.
16

17. Prior medication
To continue
Mrs SM was taking amlodipine 5 mg daily and ramipril 5 mg daily as long-term
treatment for hypertension. These were stopped at admission, presumably because
of hypotension and hypovolemia secondary to her hematemesis. Her gastrointestinal
bleeding has now stopped, her blood pressure is rising and her renal function and
potassium are normal. You should therefore now restart both medicines. It is often a
good idea to restart existing medicines around 24 hours before hospital discharge to
make sure they are still tolerated in the context of recovery from an acute illness. In
Mrs SM’s case you do not need to delay her discharge while these drugs restart.
To stop / interactions
There are no identified clinically significant interactions between new and prior
therapy and no prior medications that need to be stopped.
17

18. Communication
Patient
You should advise Mrs SM that her new medicines are to clear an infection that is
causing her ulcer and that it is important that she completes the 2-week course of
treatment. You should explain the difference between the antibiotics, which she
needs to take for 2 weeks, and the acid-suppressing medicine (PPI), which she should
take for 4 weeks in total. As most discharge medicines are provided as a 14-day
supply, she will need to get more of the acid suppressant from her GP before it runs
out. You should mention possible side effects of medicines, particularly
gastrointestinal symptoms such as sickness, loose stool and abdominal cramps. You
should advise her not to drink alcohol while taking the metronidazole as she
may experience an extremely unpleasant reaction involving flushing,
throbbing headache and vomiting (a disulfiram-like reaction).
18

19. She should also avoid any cough/cold medicines or mouthwash that contains alcohol,
as these will have the same effect. While you are on the topic you could remind her of
the safe limit for alcohol consumption and ask if she has considered stopping smoking.
It is important to remind her that she should take her blood pressure treatment as
usual from this morning and see her GP for her usual review and repeat
prescriptions.
GP
A good discharge summary concisely explaining events in hospital and changes in
treatment is essential.
This is invariably combined with the discharge prescription.
19

20. Writing a discharge prescription
This case illustrates the process of writing a discharge prescription, commonly
referred to on the wards as the TTA (to take away) or TTO (to take out). This is a very
important task which is commonly undertaken by resident doctors. We illustrate the
process on paper, but it is much the same for electronic discharge summaries, which
are increasingly the norm and will be incorporated in our hospital system very soon.
The principles of writing a discharge prescription are no different from any other form
of prescription writing, although a couple of points require particular emphasis:
● Specifying the duration of therapy, as the GP needs to know whether they are
expected to take on responsibility for providing repeat prescriptions
● Highlighting changes that have been made to the patient’s previous medication
regimen (particularly medicines that were stopped), so that the GP knows that
any differences are intentional rather than being due to oversights.
20

21. Often, dealing with the discharge prescription is the rate-limiting step between the
decision to discharge a patient and them actually leaving the hospital. It is therefore
very important both to the patient and to the smooth running of the hospital that
you deal with discharge prescriptions as expeditiously as possible. It may be helpful
to write them in anticipation of the patient going home in the next 1–2 days.
However, if you do this, you must be especially careful to ensure any last-minute
changes to their drug chart or treatment plan have been reflected in the discharge
prescription.
How do I write the prescription?
H. pylori eradication regimen
The eradication regimen shown in the model prescription was chosen to avoid
amoxicillin, as Mrs SM is allergic to penicillin. She therefore needs to receive
clarithromycin and metronidazole, which are only recommended in combination with
lansoprazole. 21

22. She has tolerated intravenous omeprazole for the past 72 hours and so oral
omeprazole is a reasonable substitute, although lansoprazole would be an acceptable
choice.
Triple therapy (PPI and two antibiotics) is usually for 2 week and this will eradicate
H. pylori and bring about ulcer healing. As Mrs SM has had a significant bleed from
her ulcer, the latest guidelines advice is to continue the PPI for 2 more weeks after
completing the eradication regimen.
The regimen has therefore been prescribed as described in the latest guidelines with
recommended doses, administration frequency and duration of treatment.
In accordance with good antibiotic prescribing principles, the indications for
antibiotic use have been given.
22

23. Anti-hypertensive medication
Amlodipine and ramipril have been prescribed on the discharge prescription. With
her blood pressure now rising she should ideally restart these sooner rather than later.
Therefore, you would also prescribe them on the inpatient prescription chart and ask
the nursing staff to administer doses this morning.
Other
As required prescriptions should generally be stopped once they are no longer
needed. You should not therefore prescribe cyclizine on the discharge prescription.
REFERENCES
1. Prescribing at a Glance. Chapter 19: How to write a drug prescription.
2. National Institute for Health and Clinical Excellence . Dyspepsia: Managing
dyspepsia in adults in primary care. Clinical guidline CG17.
23

24. A 54-year-old woman with
a peptic ulcer
1
Patient name:
ID number:
Date of birth:
Age:
Weight:
S M
100045
03/03/1966
54 years
71kg
Admission date: 04/01/2021
Date/time seen: 07/01/2021 10:00
History
Problem Routine review before discharge.
History
PMH
DH
SH
SM was admitted 3 days ago after
vomiting up blood. Over the past 3 months she
has had intermittent epigastric pain relieved by
eating and indigestion tablets. Her weight has
been steady and she has had no change in bowel
habit. On the day of admission she felt
nauseated for several hours, before vomiting up a
large amount of bright red blood and passing
black tarry stools.
On admission to hospital she received a blood
transfusion and underwent urgent endoscopy, at
which bleeding from a duodenal ulcer was
controlled.
She now feels well with a good appetite and no
abdominal discomfort. Her bowel motions are a
normal colour. Her energy levels are good, she
has no shortness of breath and she is keen to
get home as soon as possible.
Pre-eclampsia, hypertension.
At admission: amlodipine 5
mg daily, ramipril 5
mg daily (both withheld during the admission).
Started during the admission: 72-hour IV
infusion of high-dose omeprazole completed this
morning, cyclizine 50
mg IV/IM 8-hourly as
required (last dose 3 days ago).
Drug Allergies: Penicillin.
She smokes 10 cigarettes and drinks 60 ml of
vodka per day.
Examination
General She looks well.
Obs T 36.7°C, HR 72 beats/min, BP 168/96 mmHg, RR
13 breaths/min, SpO2 98% breathing air.
Abdo Soft, non-tender.
Investigations
Endoscopy report 04/01/2021:
• Normal oesophagus and stomach.
• Moderate-sized ulcer in duodenum, visible vessel in base,
injected with adrenaline. Good hemostasis achieved.
• Campylobacter-like organism (CLO) test positive for Helico-
bacter pylori.
Task
Mrs S M is now ready for discharge. Review her treat-ment
and prescribe her discharge medication as appropriate.

25. Case1 A 54-year-old woman with a peptic ulcer
DISCHARGE SUMMARY
Surname Hospital number
First name Date of birth
Address Drug Allergies
Diagnosis
Other diagnoses and summary of management
Medicines to take away
Date of admission Ward
Date of discharge Consultant
General practitioner name and address
DRUG DOSE FREQ ROUTE DURATION CONTINUE COMMENTS

26. AnswerKey:- A 54-year-old woman with a peptic ulcer
DISCHARGE SUMMARY
Surname Hospital number
First name Date of birth
Address Drug Allergies
Diagnosis
Other diagnoses and summary of management
Medicines to take away
Date of admission Ward
Date of discharge Consultant
General practitioner name and address
DRUG DOSE FREQ ROUTE DURATION CONTINUE COMMENTS