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1. DRUGS USED IN TREATMENT
OF PEPTIC ULCERS DISEASES
BY
SSEMUWEMBA FRANK
0712319897/0706319897

2. PRESENTATION OUTLINE
1. ANTI-ACIDS e.g Magnesium and Aluminum
2. H2 RECEPTOR ANTAGONISTS e.g Cimetidine,
Ranitidine and Famotidine
3. PROTON PUMP INHIBITORS e.g Omeprazole,
Pantoprazole, Lansoprazole and Esomeprazole and
Rabeprazole
4. ANTISPASMODICS e.g Hyoscine butyl bromide and
Drotaverine
5. ANTIBIOTICS e.g Amoxicillin, Metronidazole and
Clarithromycin.

3. This is an ulceration in the stomach or duodenum or
both resulting from an imbalance between defense
mechanisms (protective factors) and various mucosal
damaging mechanisms (HCL/pepsin secretion).
It is a chronic condition with natural history of
spontaneous relapses and remissions.
Classification of PUD
Gastric ulcer (occurs in the stomach-single& lie on the
lesser curvature)
Duodenal ulcer (occurs in the duodenum-duodenal
cup-1st part of duodenum)
Cause: Exact cause is unknown
Definition of PUD
SSEMUWEMBA FRANK
0706319897/0712319897

4. PUD
SSEMUWEMBA FRANK
0706319897/0712319897

5. GASTRIC ULCERS
SSEMUWEMBA FRANK
0706319897/0712319897

6. GASTIRIC ULCER
SSEMUWEMBA FRANK
0706319897/0712319897

7. PUD (DU& GU)
SSEMUWEMBA FRANK
0706319897/0712319897

8. Risk factors
SSEMUWEMBA FRANK
0706319897/0712319897

9. H2 RECEPTOR ANTAGONISTS
H2 receptor antagonists reduce gastric acid
secretion by blocking the action of histamine at the
H2 receptor in the parietal cells of the stomach
Examples
Cimetidine
Famotidine
Nizatidine
Ranitidine

10. 1. CIMETIDINE
Preparations (tagament/lock2/tenomet=brands)
1. Tablets 200mg, 400mg
2. Injection 100mg/ml, 2ml
Pharmacokinetics
Cimetidine is readily absorbed from GIT when given
orally.
 Food delays rate and may slightly decrease the
extent of absorption.
It is widely distributed and partly metabolised in the
liver.
Cimetidine crosses the placenta barrier and is
distributed into milk.

11. Pharmacokinetics cont’d
Its excreted mostly in unchanged form in urine.
Indications
Peptic ulcers
Stress ulcers in critically ill patients
Reflux oesophagistis
Zollinger-ellison syndrome
Dyspepsia
Contraindications
Hypersensitivity to other H2 antagonists

12. Zollinger Ellison syndrome
A rare disorder in which there is excessive secretion
of gastric acid due to high levels of circulating gastrin
hormone produced by a pancreatic tumor or
enlarged pancreas.
High levels of HCl in stomach causes diarrhea and
PUD which may be multiple in unusual sites e.g
jejunum or which may recur quickly after vagotomy
or gastrectomy.
Rx is by PPI, removal of tumor is benign or by total
gastrectomy.

13. DOSE
Oral route
Gastric ulcers and duodenal ulcers: 400mg twice daily
or 800mg at night for 4-6 weeks.
Maintenance: 400mg at night.
Reflux oesophagitis : 400mg 4times daily for 4-8 weeks
Prophylaxis of stress ulceration: 200mg-400mg every
4-6hours.
Zollinger-ellison syndrome: 400mg 4times daily
(maximum dose is 2.4g daily).
Gastric acid reduction, obstetrics: 400mg at start of
labour then up to 400mg every 4hours if required
(max2.4g daily).

14. Dose
Oral route
Drug Dose Duration
Gastric ulcers and duodenal ulcers
Maintenance
400mg or
800mg
400mg
Twice daily
At night 4-6weeks
At night
Reflux oesophagitis 400mg 4times daily for 4-6hours
Prophylaxis of stress ulceration 200mg-400mg Every 4-6hours
Zollinger-ellison syndrome 400mg 4times daily (maximum dose is 2.4g
daily)
Gastric acid reduction, obstetrics 400mg then
400mg
At start of labour up to
Every 4hours if required (max 2.4g daily)
Dyspepsia 200mg Up to 4times daily 4-8weeks.
Parenteral route
Slow intravenous injection 200mg 4-6hrs over at least 2minutes &diluted
in 20ml of normal saline
Intravenous infusion 400mg in
100ml
of sodium chloride 0.9% infused
over30mins-1hr repeated every 4-6hrs

15. Side effects
Dizziness Headache
Nausea Vomiting
Reversible impotence Loss of libido
Mild gynaecomastia Diarrhoea
Tiredness
Drug interactions
Antacids may decrease the absorption of cimetidine
The effect of ferrous Sulphate, Indomethacin,
Ketoconazole, Fluconazole and Tetracycline may be
decreased by Cimetidine due to decreased
absorption.

16. Drug interactions cont’d
Metoclopramide may reduce the bioavailability of
cimetidine due to reduction of gastrointestinal
transit time.
Cimetidine decreases the metabolism of phenytoin,
metronidazole, oral contraceptives, warfarin and
isoniazid.
Key issues to note
Administer cimetidine with food but not with anti-
acids
The preferred method of administration of
Parenteral cimetidine is by continuous infusion but
may be given intramuscularly.

17. Key issues cont’d
Advise the patient to avoid excessive amount of
coffee or aspirin
Cimetidine has a weak anti-androgenic effect hence
gynaecomastia, impotence and loss of libido may
occur.
2. FAMOTIDINE
Preparations: Tablets 20mg, 40mg
Pharmacokinetics
Famotidine readily but incompletely absorbed from
the gastrointestinal tract partially metabolised in
the liver and is excreted unchanged in the urine .it
is also found in breast milk.

18. Indications
Reflux oesophagitis
Zollinger-Ellison syndrome
Benign gastric ulcer
Duodenal ulcer
Dyspepsia
Contraindications
Hypersensitivity to Famotidine
Gastric malignancy
Lactation
Children

19. Side effects
Headache Dry mouth Fatigue
Abdominal discomfort Flatulence Fever
Nausea and vomiting Anxiety
Constipation Anorexia
Dose
Drug Dose Duration
Gastric and duodenal ulceration
Maintenance
40mg
20mg
4-8weeks at night
At night (duodenal ulcer)
Zollinger-Ellison syndrome 20mg 6hourly daily for along period of
time
Reflux oesophagitis
Maintenance
20-40mg
20mg
Twice daily for 6—12 weeks
Twice daily.

20. Drug interactions
Famotidine reduces absorption of ketoconazole,
itraconazole, cefpodoxime, cefuroxime to reduce
gastric acidity.
Famotidine increases the absorption of glipizide,
tolbutamide which lead to hypoglycaemia
3. RANITIDINE
Preparation: Tablets 150mg, 300mg
Injection 25mg/ml (2ml)
Pharmacokinetics
Ranitidine is readily absorbed from the gastrointestinal
tract, widely distributed, metabolised in the liver and is
excreted in urine.

21. Indications
Peptic ulcer
Prophylaxis of NSAID induced duodenal or gastric
ulcer
Stress ulcer prophylaxis
Gastro esophageal reflux disease
Zollinger-Ellison syndrome
Dyspepsia
Contraindications
Patients allergic to ranitidine
Children less than 8years.

22. Dose
Peptic ulcer
Adults and children over 12 years: 150mg twice
daily or 300mg at night 4-8weeks.
Prophylaxis of NSAID induced duodenal or gastric
ulcer: 150mg twice daily prn.
Gastro oesophageal reflux disease: 150mg twice
daily or 300mg at night up to 8 weeks.
Moderate to severe cases 150mg 6 hourly daily
for up to 12 weeks.
Zollinger-Ellison syndrome: 150mg 3 times daily
Stress ulcer prophylaxis 150mg twice daily until
risk factor is removed.

23. Dose cont’d
Dyspepsia; 150mg twice daily for 4-8 weeks
IV: 50mg diluted to 20ml with normal saline or
dextrose 5% every 6-8 hours by slow injection over not
less than 5min.
IV infusion: 25mg/ hour for 2hours may be repeated
every 6-8hours.
Side effects
Skin rash Malaise
Visual disturbance Tachycardia
Gynaecomastia Constipation
Headache Hypersensitivity
Diarrhoea Myalgia

24. Drug interaction
Anti acids may decrease the absorption of ranitidine
Ranitidine may decrease the absorption of
ketoconazole, cefpodoxime, cefuroxime.
Ranitidine may increase the hypoglyceamic effects
of Glipizide.
Ranitidine may interfere with warfarin clearance.

25. PROTON PUMP INHIBITORS (PPIS)
These act by irreversibly binding to and inhibiting the
enzyme H+ /K+ ATpase (proton pump) of the gastric
parietal cells resulting into long lasting but reversible
acid suppression.
Proton pump inhibitors, inhibit gastric acid secretion
more than the H2 receptor antagonist.
Examples
Omeprazole
Lansoprazole
Pantoprazole
Esomeprazole
Rabeprazole

26. 1. OMEPRAZOLE
Preparation
1. Enteric coated Capsules/Tablets 20mg
Pharmacokinetics
It is rapidly but variably absorbed after oral
administration.
Absorption is not affected by food
It is almost completely metabolised in the liver and
80% of the metabolites are excreted mainly in urine
and the rest in feaces.

27. Indications
Peptic ulcers
Zollinger-Ellison syndrome
NSAID associated duodenal or gastric ulcer
Gastric acid reduction during anesthesia
Gastro oesophageal reflux disease
Acid related dyspepsia.
Contraindications
Allergy to omeprazole or any other component in
the capsule.
Pregnancy
Lactation

28. Dose
Gastric ulcer or reflux oesophagitis: 20-40mg daily for
4-8weeks.
Duodenal ulcer: 20mg once daily for 4weeks
NSAID associated duodenal or gastric ulcer: 20mg
once daily for 4weeks continued for further 4weeks if
not fully healed.
Zollinger-Ellison syndrome: Initially 60mg once daily,
usual range 20-120mg with doses over 80mg given in 2
divided doses.
Acid related dyspepsia: 20mg once daily for 2-4
weeks.,
Prophylaxis of acid aspiration: 40mg on the proceeding
evening then 40mg 2-6 hrs before surgery.

29. Side effects
Headache Nausea Impotence
Vomiting Flatulence Gynaecomastia
Constipation Abdominal pain
Skin Rashes Dry mouth
Drug interaction
Omeprazole increases the plasma concentration of
diazepam, carbamazepine, digoxin, phenytoin.
It decreases the plasma concentration itraconazole,
ketoconazole, cefpodoxime, cefuroxime, iron salts
and cyanocobalamin.
It may increase the absorption and the potential for
hypoglycaemia of glipizide, tolbutamide.

30. Key issues
Administer before and the capsule should be
swallowed whole without chewing.
Capsules should be used within one month of
opening the package.
Possible malignancy must be excluded prior to
starting treatment to avoid delay of the diagnosis.
Dosage reduction may be required in hepatic
disease.

31. 2. ESOMEPRAZOLE
Preparations: Tablets 20mg, 40mg
Pharmacokinetics
Esomeprazole is a rapidly absorbed following oral
administration .
It is extensively metabolised by the liver and
excreted in the urine and a small percentage in
faeces.
Contraindications
Known hypersensitivity to benzimidazole
Pregnancy

32. Indications
Gastro oesophageal reflux disease
Zollinger-Ellison syndrome
Peptic ulcer disease
Prevention of relapse of H pylori associated peptic ulcer
Prevention of gastric and duodenal ulcers associated
with NSAID therapy.
Dose
Peptic ulcer disease: Triple therapy regimen 40mg of
esomeprazole once daily amoxicillin 1g twice daily and
clarithromycin 500mg twice daily for 7days

33. Dose cont’d
Gastro esophageal reflux disease: 40mg once daily
for 4-8weeks depending on the response,
maintenance : 20mg daily.
Gastric ulcer associated with NSAID therapy: 20mg
once daily for 4-8weeks.
Side effects
Taste disturbances Headache
Dizziness Abdominal pain
Diarrhoea Skin Rash
Nausea Vomiting
Dry mouth Flatulence

34. Drug interaction
Reduction in gastric acidity due to Esomeprazole
may decrease absorption of ketoconazole,
itraconazole, digoxin and iron.
Key issues
Food delays and decreases the absorption of
Esomeprazole, therefore take it at least 1 hour
before meal.
The tablet should be swallowed whole: do not chew
or crush.

35. 3. LANSOPRAZOLE
Preparations : Capsule 30mg
Pharmacokinetics
It is rapidly absorbed after oral administration,
extensively metabolised in the liver and metabolites
are excreted primarily in faeces via the bile.
Indications
Peptic ulcers
Zollinger-Ellison syndrome
Gastro oesophageal flux disease
Acid related dyspepsia
Prophylaxis of NSAID associated duodenal and
benign gastric ulcer.

36. Contraindications
Hypersensitivity to Lansoprazole
Breast feeding
Pregnancy
Dose
Benign gastric ulcer: 30mg daily in the morning for
8weeks
Duodenal ulcers: 30mg daily in the morning for
4weeks, maintenance 15mg daily.
Zollinger-Ellison syndrome: Initially 60mg once
daily adjusted according to response to daily dose
of 120mg or more in 2 divided doses.

37. Dose cont’d
Gastro oesophageal reflux disease: 30mg daily in
the morning for 4-8weeks, maintenance: 15-30mg
daily
Acid related dyspepsia: 30mg daily in the morning
for 2-4weeks
Side effects
Abdominal pain Diarrhoea or Constipation
Fatigue Nausea &Vomiting
Dizziness Flatulence & malaise
Headache Skin Rash
Altered appetite Impotence

38. Drug interactions
It may interfere with the absorption of drugs where
gastric PH is an important determinant of
bioavailability such as ketoconazole, itraconazole,
ampicillin, iron salts, digoxin.
Antacid may reduce absorption of Lansoprazole
when given at the same time.
It may also reduce the effect of oral contraceptives,
phenytoin, carbamazepine, warfarin and
theophylline .

39. Key issues to note
Swallow capsule whole without crushing or chewing
For patients un able to swallow, open the capsule and
pour the contents on a tea spoon and swallow
Take the drug after meal
4. RABEPRAZOLE
Preparations
 Tablets 20mg
 Injection 20mg/ml
Pharmacokinetics
It is rapidly absorbed from the git and is 96% protein
bound .it is extensively metabolised in the liver and
excreted principally in the urine
It crosses the placenta and may enter breast milk.

40. Indications
Peptic ulcers
Gastro oesophageal reflux disease
Helicobacter pylori eradication in combination with
antibiotics
Zollinger-Ellison syndrome
Contraindications
Hypersensitivity to rabeprazole
Gastric malignancy
Pregnancy
Lactation.

41. Dose
Benign gastric ulcer: 20mg daily in the morning 6-
12weeks.
Gastro oesophageal reflux disease: 20mg once for
4-8weeks.
Maintenance: 10-20mg daily
Duodenal ulcer: 20mg daily in the morning for 4-
8weeks.
Zollinger-Ellison syndrome: initially 60mg once
daily adjusted according to the response up to a
max of 60mg twice daily.
Note Children not recommended

42. Dose cont’d
Tripple therapy regimen: Rabeprazole 20mg twice
daily combined with clarithromycin 500mg twice
daily and either amoxicillin 1g twice daily or
metronidazole 400mg twice daily for 7days.
Side effects
Headache Nausea
Abdominal pain Cough
Flatulence Insomnia
Constipation or diarrhoea Dry mouth
Skin rash Anorexia
Influenza-like syndrome Rhinitis

43. Drug interaction
Co-administration of Rabeprazole with ketoconazole
decreases ketoconazole plasma level.
It may increase serum levels and toxicity of
benzodiazepines when given together.
5. PANTOPRAZOLE
Preparation
 Tablets 20mg, 40mg
Pharmacokinetics
Pantoprazole is rapidly absorbed from the gastro
intestinal tract and is 98%protein bound.
It is extensively metabolised in the liver and excreted
principally in the urine.

44. Indications
Peptic ulcers
Gastro oesophageal reflux disease
Zollinger-Ellison syndrome
Prevention of NSAID induced ulcer
Contraindications
Hypersensitivity to Pantoprazole
Lactation
Dose
Gastro oesophageal reflux disease: 20mg-40mg
daily in the morning for 4-8weeks. Maintenance:
20-40mgdaily.

45. Dose cont’d
Duodenal ulcer: 40mg daily in the morning for 2-
4weeks
Zollinger-Ellison syndrome: initially 80mg once
daily, adjusted according to response.
Elderly: max dose is 40mg daily
Prophylaxis of NSAID associated gastric or
duodenal ulcer :20mg daily.
Benign gastric ulcer: 40mg daily in the morning for
4-8weeks.
Children: not recommended.

46. Side effects
Constipation Dizziness
Pruritus Flatulence
Chest pain Headache
Anxiety Skin rash
Abdominal pain Fatigue
Drug interaction
Pantoprazole may decrease the absorption of
ketoconazole and itraconazole.

47. ANTIBIOTICS
Antibiotics are recommended in the treatment of
PUD when H pylori is confirmed.
They are given in triple therapy in combination with
proton pump inhibitors.
Common Abcs used in triple therapy include:
Amoxicillin
Clarithromycin
Metronidazole
Tinidazole
Tetracycline

48. Risk factors
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49. Tripple therapy regimen for eradication of
H. pylori infection (7days treatment)
Proton pump inhibitor
(acid suppressant)
Amoxicillin Clarithromycin Metronidazole
Esomeprazole
20mg twice daily
1g bd 500mg bd
250mg bd 400mg bd
Lansoprazole
30mg twice daily
1g bd
1g bd
500mg bd
500mg bd
400mg bd
400mg bd
Omeprazole
20mg twice daily
1g bd
500mg tds
500mg bd
500mg bd
400mg tds
400mg bd
Pantoprazole
40mg twice daily
1g bd 500mg bd
500mg bd 400mg bd
Rabeprazole
20mg twice daily
1g bd 500mg bd
500mg bd 400mg bd

50. PPI’s ABCs ABCs ABCS
Omeprazole 20mg
bd
Amoxicillin 500mg
tds/1g bd
Metronidazole 400mg
bd/tds
Clarithromycin 250-
500mg bd
Lansoprazole 30mg bd 1g bd/500mg tds 400mg bd/tds 250-500mg bd
Pantoprazole 40mg
od/bd
1g bd 400mg bd 250-500mg bd
Rabeprazole 20mg od 1g bd 400mg bd 250-500mg bd
Esomeprazole 20mg
bd
1g bd 400mg bd 250-500mg bd
Recommended regimens for H.pyroli
Use only two ABCs & one PPI
SSEMUWEMBA FRANK
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51. ANTISPASMODICS
These drugs reduce spasms associated with peptic ulcer
and other GIT disorders .
Examples
Hyoscine butylbromide (BUSCOPAN)
Drotaverine (NOSPA)
Propantheline
1.HYOSCINE BUTYLBROMIDE
Preparation
1. Tablets 10mg
2. Syrup 5mg/5ml
3. Injection 20mg/ml

52. Mode of action
Hyoscine butylbromide exerts a spasmolytic
action on the smoth muscle of the
gastrointestinal, biliary and Genito-urinary tracts.
Indications
Prevention of motion sickness.
Other forms of nausea and vomiting.
Relieve pain of GI spasm (bowel colic).
Premedicant in anaesthesia.
Adjunct in the peptic ulcer disease treatment.

53. Contraindications
Reduced bronchial secretion Megacolon
Closed angle glaucoma Pyloric stenosis
Hypersensitivity Porphyria
Prostatic enlargement
Dose
By mouth
Adults: 20mg 4 times daily
Children: 6-12 years: 10mg 3 times daily
Injection
Adult; IM/IV: 20mg 3-4 times daily.

54. Side effects
Dry mouth Flushing of the skin
Tachycardia Fatigue
Increased intraocular pressure Blurring of vision
Reduced bronchial secretion Constipation
Acute urinary retention Drowsiness
Drug interaction
Additive sedative effects with alcohol or other CNS
depressants.
Concomitant use with dopamine antagonists eg
metoclopramide, may result in diminution of the
effects both drug on the GIT.

55. 2. DROTAVERINE
Preparation
 Tablets 40mg, 80mg
 Injection 40mg/2m/
Mode of action
It inhibits phosphodiesterase enzyme IV, leading
to elevated intracellular cAMP levels which in turn
leads to relief of spasm thereby relieving the pain.
It also exerts an anti-inflammatory activity similar
to the NSAIDs.

56. Indications
Drotaverine is used as an antispasmodic in the
management of pain associated with:-
Biliary colic
Renal colic
Dysmenorrhoea
Contraindications
Hypersensitivity to Drotaverine Porphyria
Pregnancy and lactation
Severe hepatic impairment
Severe renal impairment
Intestinal obstruction
Cardiac insufficiency

57. Dose
Adults: 40mg-80mg 8 hourly prn
Children: >6years; 40mg 8hourly
1-6years; 20mg 8hourly
Side effects
Dizziness
Nausea
Headache
Allergic reaction
Drug interaction
It may decrease the anti-parkinsonian effect of
levodopa, tremors and rigidity may increase.

58. 3. PROPANTHELINE
Preparation
 Tablets 15mg
Mode of action
It inhibits GI motility and diminishes gastric acid
secretion.
Indications
Adjunct in the treatment of peptic ulcer disease
Irritable bowel syndrome
Urinary frequency and enuresis (adults)
Pancreatitis.

59. Contraindications
Narrow angle glaucoma.
Obstructive disease of the GI tract.
Chronic lung disease.
Hypersensitivity to the drug.
Bladder neck obstruction due to prostatic
hypertrophy.
Dose
Adults :15mg 3times on hour before meals and 30mg
at night max 120mg daily.
Elderly: 7.5mg 3times daily.
Children: antispasmodic; 2-3mg/kg/day in 3divided
doses.

60. Side effects
Sensitivity to light Thirst
Tachycardia Flushing
Decreased sweating Arrhythmias
Orthostatic hypotension
Blurred vision
Dry mouth with difficult in swallowing
Urinary hesitancy and retention
Increased ocular pressure
Drug interactions: concomitant administration with
tricyclic ant depressants may result in additive anti-
cholinergic effect.

61. • PUD can be acute or chronic, acute PUD may
bleed/perforate without prior symptoms especially
duodenal ulcers
• Chronic PUD develop from acute ulcers that fail to
heal.
THANK YOU FOR
WRITING AND
LISTENING
PUD is break in the epithelial surface of the
esophagus, stomach or duodenum caused by action
of HCL acid secretion or pepsin or both
SSEMUWEMBA FRANK
0706319897/0712319897