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Irrational use of drugs will affect the treatment of the disease and even lead to the
deterioration of the disease.
Below we summarize the common irrational drug use as follows through 7 cases, hoping to attract clinical attention
.
Case 1
of gestationClinical diagnosis: gastric ulcer
prescription: Ilaprazole enteric-coated tablets 10mg qd
.
Analysis: Drug selection is not appropriate
.
Clinical data on the use of PPIs in pregnant women are limited
.
It is not recommended for pregnant women except for refractory and severe gastroesophageal reflux disease
.
Avoid using any PPIs
in the first 1 month of pregnancy and the 1~3 months of pregnancy.
According to the drug label, FDA pregnancy grading, and the latest clinical guidelines, only omeprazole is grade C and can be used
during pregnancy.
It is recommended that the patient should first adjust the living and diet, and if it cannot be relieved, he can take antacids such as sodium bicarbonate, aluminum magnesium carbonate and gastric mucosal protectors
.
When the above treatment effect is not good, the benefit and risk of the patient is fully assessed before the use of PPI is considered, and omeprazole
is preferred.
Table 1 Application of PPI in special populations [1] Remarks: *This part refers to the drug labels, FDA pregnancy grading and the latest clinical diagnosis and treatment guidelines of domestic original drugs
Case 2
Clinical diagnosis: coronary heart disease, gastric ulcer
prescription: clopidogrel hydrogen sulfate tablets oral 75mg qd, injection with esomeprazole sodium intravenous infusion 20mg qd solvent sodium chloride injection 100ml
Analysis: Drug selection is not appropriate
.
Clopidogrel is mainly metabolized by CYP2C19 to produce activity, and esomeprazole can compete with it during metabolism with CYP2C19, which reduces the efficacy of clopidogrel and increases the risk of adverse events of myocardial infarction, so this combination is not recommended
.
It is recommended to replace esomeprazole with drugs that have a relatively small effect on the antiplatelet effect of clopidogrel, such as pantoprazole, rabeprazole, etc
.
Case 3
.
He has a history of hypertension and diabetes for more than
10 years.
Denial of drug and food allergies
such as penicillin and cephalosporin.
ECG: sinus rhythm; Ventricular premature beats: prolongation
of the Q-T interval.
C13 Breath test (+), gastroscopy showing antral ulcer (stage H1),
diagnosis: Helicobacter pylori infection
prescription: omeprazole + clarithromycin + levofloxacin + colloidal pectin bismuth
Analysis: At present, the consensus in China recommends bismuth quadruple (PPI + bismuth + 2 antibacterial drugs) as the main empirical treatment eradication program (see Table 2 for the recommended 7 regimens
).
However, due to the large adverse reactions of tetracycline and furazolidone and the lack of access to drugs in most regions of China, it is difficult for the scheme containing tetracycline or furazolidone to be widely used in clinical practice
.
Therefore, amoxicillin, clarithromycin, metronidazole, and levofloxacin are more commonly used
in comparison.
Both clarithromycin and levofloxacin were associated with
a significant prolongation of the QTc interval.
One of the main metabolizing enzymes of omeprazole and clarithromycin is CYP3A4, which is also an inhibitor of the enzyme, and the combination of the two can compete for the metabolizing enzyme and the inhibitory effect of the enzyme to increase
the blood concentration of each other.
Increased clarithromycin plasma concentrations may further exacerbate the prolongation
of the Q-T interval.
For patients at risk of QTc prolongation, the American Gastroenterological Association (ACG) [2] recommends first-line therapy with bismuth quadruple therapy
excluding clarithromycin and levofloxacin.
Table 2 The combination, dosage and usage of antibacterial drugs recommended by the fifth consensus of China in the Hp eradication quadruple regimen [3].
Case 4
Clinical diagnosis: gastric ulcer
prescription: sucralfate suspension gel 1g bid, rabeprazole sodium enteric-coated tablets 10mg QD
analysis: PPI acid inhibitory effect is strong and long-lasting, so it is not suitable to use other antacids or antacids
during medication.
Antacids (sucralfate (sucralfate , aluminum hydroxide, magnesium oxide, sodium bicarbonate) need to function under acidic conditions, lose the acidic environment and cannot exert efficacy, and sucralfate can also interfere with the absorption of PPI and reduce its bioavailability
.
If the two are combined, the interval between doses should be more than
2 hours.
Case 5
Clinical diagnosis: hypertension, gastric ulcer
prescription: compound reserpine triamterene tablets 1 tablet QD, rabeprazole sodium enteric-coated tablets 10mg QD
analysis: Reserpine can promote excessive secretion of gastric acid, inducing or aggravating gastric ulcer bleeding
.
Therefore, patients with stomach diseases should avoid using antihypertensive drugs containing reserpine when choosing antihypertensive drugs, and the instructions of these drugs are also clearly marked "prohibited in patients with gastric and duodenal ulcers"
.
Case 6
Clinical diagnosis: chronic gastritis with erosion
prescription: lansoprazole 30mg, solvent: 5% glucose injection 250mL
.
Analysis: Inappropriate choice of solvent
.
PP is highly dependent on pH, and the injections contain NaOH to adjust pH to increase stability
.
Glucose is an acidic solution, and using it as a solvent will cause lansoprazole to be unstable and easy to discolor, so it should be formulated using 0.
9% sodium chloride injection
.
Case 7
, clinical diagnosis: liver cirrhosis decompensated with esophageal varices, gastric ulcer
prescription: esomeprazole enteric-coated tablets 40 mg PO bid.
Analysis: Esomeprazole enteric-coated tablets should be reduced in patients with severe liver function impairment, and the maximum daily dose should be limited to 20 mg
in patients with decompensated cirrhosis and esophageal varices.
Where to see more cutting-edge information on digestive liver disease? Come to the "doctor's station" and take a look 👇
References:
[1] Guangdong Pharmaceutical Association.
Prophylactic use of proton pump inhibitors and prescription streamlining expert guidance[J].
Clinical Medical Research and Practice, Vol.
4, No.
21, Cover 3, 2019.
[2] Helicobacter pylori and peptic ulcer science group, Chinese Society of Gastroenterology Branch, National Helicobacter pylori research cooperation group.
Fifth National Consensus Report on the Management of Helicobacter Pylori Infection.
Chinese Journal of Internal Medicine.
2017.
56(7):532-545.
[3] Nguyen CT,Davis KA,Nisly S,Li J.
Treatment of Helicobacter pylori in Special Patient Populations.
Pharmacotherapy.
2019 Aug 10.
doi:10.
1002/phar.
2318.
[4] National Health Commission of the People's Republic of China.
Guidelines for the clinical application of proton pump inhibitors(2020 edition)[J].
Chinese Journal of Practical Rural Doctors,2021,28(1):9.
)
