Patient Profile

I. Name: Mr. BD

II. Age: 62 yrs

III. PMH:
- Percutaneous Coronary Intervention (PCI) w/ Bare Metal Stent (BMS) due to Non-ST-Elevated Myocardial Infarction (NSTEMI) 4 months ago

IV. Current Medications:

1. Aspirin (Dispersible) 75 mg - antiplatelet - DAPT w/ clopidogrel
2. Clopidogrel 75 mg - antiplatelet - DAPT w/ aspirin - P2Y12 inhibitor
3. Ramipril 2.5 mg bid - antihypertensive (ACE inhibitor)
4. Simvastatin 40 mg qd - anticholesterol (Statin)
5. Atenolol 100 mg - antihypertensive beta blocker
6. Glycerin trinitrate (GtN) spray prn (SL) - anti-angina

V. Lifestyle
1. Ceased smoking 2 years prior
2. Alcohol intake in moderation
3. Non-obese

VI. Major symptoms

1. Hematemesis - vomiting up blood - 60% of hematemesis is related to peptic ulcer
2. Melaena - dark black, tarry feces - related with upper GIT bleeding

VII. Particulars
1. Mr. BD is currently undergoing DAPT (Dual Antiplatelet Therapy) due to PCI w/ BMS. However, DAPT may be discontinued after 1 to 3
months of continuous therapy.
2. There is no lab result confirming bacterial infection as the primary cause for peptic ulcer. Stress may play a factor but not in a major setting.
Dietary factors may have exacerbated the current situation.
3. Drug-drug interactions are possible with medications commonly prescribed for peptic ulcers.
4. DAPT may be the primary cause of the peptic ulcers, but it has to be assessed if DAPT may be discontinued. In this case, this is an
NSAID-induced ulcer. Older ages are much more susceptible to GIT complications.
5. Since there is no bacterial infection, antibiotics should be ruled out. Remaining medical options are H2-receptor antagonists, PPIs, antacids &
Mucosal Protective Agents (misoprostol & sucralfate).
VIII. Possible Medication Therapy
Medication Class Examples MOA Safety Profile Considerations

Proton Pump Inhibitors Omeprazole, Inhibit gastric acid Generally well-tolerated, PPIs are commonly used in combination with
Esomeprazole, secretion by irreversibly with few significant drug antiplatelet therapy to reduce the risk of
Pantoprazole, blocking the proton interactions. gastrointestinal bleeding.
Lansoprazole, pump in parietal cells.
Rabeprazole May increase the risk of However, concurrent use of clopidogrel with some
Clostridium difficile PPIs (e.g., omeprazole) may reduce the antiplatelet
infection, pneumonia, and effect of clopidogrel, so selecting a PPI with
bone fractures with minimal interaction potential (e.g., pantoprazole)
long-term use. may be preferred.

H2-Receptor Antagonists Ranitidine, Famotidine, Block histamine H2 Generally well-tolerated, H2 receptor antagonists are less potent than PPIs
Cimetidine receptors on parietal with few significant drug but may be appropriate for mild to moderate cases
cells, reducing gastric interactions. of peptic ulcer disease.
acid secretion.
May cause reversible They are less likely to interact with antiplatelet
elevation of serum medications compared to PPIs.
creatinine and CNS
effects (e.g., confusion,
agitation) in elderly
patients.

Mucosal Protective Agents Sucralfate, Misoprostol Sucralfate forms a Generally well-tolerated, Mucosal protective agents are less commonly used
protective barrier over with minimal systemic as first-line therapy but may be considered in
ulcers and erosions, absorption and few specific cases, such as NSAID-induced ulcers
promoting healing. significant drug (misoprostol) or as adjunctive therapy (sucralfate).
interactions.
Misoprostol is a
synthetic prostaglandin May cause constipation or
analog that inhibits diarrhea.
gastric acid secretion and
stimulates mucus and
bicarbonate production.
Antacids Aluminum Hydroxide, Neutralize gastric acid, Generally well-tolerated, Antacids are most commonly used for
Magnesium Hydroxide, providing rapid relief of but long-term use may symptomatic relief rather than ulcer healing. They
Calcium Carbonate symptoms. lead to electrolyte can be used intermittently for breakthrough
imbalances (e.g., symptoms but are not typically recommended as
hypermagnesemia with sole therapy for peptic ulcers.
magnesium-containing
antacids) or rebound acid
hypersecretion.

IX. Management
1. Alcohol intake must be stopped immediately.
2. Confirm if the ulcer is NSAID-induced/DAPT-induced. Symptoms point to the aforementioned types of ulcers.
3. Conduct a physical exam.
4. Esophagogastroduodenoscopy (EGD) or endoscopy should be done to confirm the presence of ulcers and assess the risk of bleeding.
5. Patients should be admitted and observed, as hematemesis & melaena are already severe symptoms of peptic ulcers. Benefits of DAPT may be
overshadowed by possible GIT bleeding.
6. Monitoring should be conducted for both peptic ulcer symptoms & possible cardiac events if DAPT is replaced by clopidogrel therapy alone or
discontinued.
7. Administration of a PPI that does not interact or has limited interaction with DAPT should be done immediately to alleviate the symptoms of
peptic ulcer. Adjunctive therapy by mucosal protective agents are advised.