Question

Age: 26 day

Gender: female

Diagnosis: PUD in nursing mother

Rx

Omeprazole T one od

Note: urea breath test was +ve , patient is allergic to penicillin.

according to this prescription find the mistakes, the interaction, dose , the toxicity level , antidotes , the counselling and what the suitable medication for this patient ?

Answer 1

Patient description- The patient is of peptic ulcer disease and is breastfeeding a child -

Test done- Urea breath test positive- Indicative of bacteria with urease enzyme- most probably- H. Pylori

Point to remember in this case- patient is allergic to penicillin

Mistakes in prescription-

The dose of Omeprazole is not mentioned.

The patient has an active bacterial infection which needs antibiotics for it. Which is not there in the prescription.

Drug name should be in capital letter.

Signature of the prescriber must be there.

Interaction-

Each and every medicine interact differently.

Omeprazole act on the proton pump in the gastic antral cells and permanently inactive it. The cells regenerate itself within 24 hrs, therefore making the efficiency of the medicine work for less than a day so 2 doses need to be given.

Nsaids should be avoided because it supress prostaglandins which further lead to aggrevation of ulcer.

Now here we have to select antibiotics carefully because patient is allergic to penicillin and a variety of antibiotics passes through the breast milk.

If we give penicillin antibiotics it will lead to anaphylaxis which in turn is dangerous.

Clarithromycin interaction with many agents hence to be careful before administration-

Clarithromycin should not be given with ergots, midazolam- increase chance of toxicity.

Clarithromycin with Cisapride, Terifenadine- causes QT prolongation

Clarithromycin should not be given in hypokalemia also causes QT prolongation.

Clarithromycin should not be used in patients with renal and liver impairment.

Clarithromycin with oral antidiabetic drug result in significant hypoglycemia

Carefully use with anticoagulant as it increases the risk of hemorrhage due to elevation of international normalised ratio.

Clarithromycin inhibit cyp3a enzyme. Therefore cyp3a have narrow margin of safety like carbamazepine.

Dose and suitable medication

In this case of H. Pylori we need to combine 3 drug regimen which are the first line for the management of peptic ulcer.

Rx

OMEPRAZOLE 20 mg BID

CLARITHROMYCIN 500 mg BID

METRONIDAZOLE 500 mg BID

Toxicity level-

As such there are side effects associated with each and every of them.

Omeprazole- No toxic level reported in human but as per as research it is 4000mg/kg in mouse

Clarithomycin- large dose of clarithromycin can cause symptom like dizziness, gi symptom.

A patient with bipolar disorder had 8gm of clarithromycin which leads to aggravation of symptom like paranoid behaviour, alter mental status and also cause hypokalemia.

Antidote-

If a person has taken large amount of dose-

Immediately perform gastric lavage with activated charcoal to remove excess drug from the body.

Supportive measure should be done because there is no specific antitode.

Peritoneal dialysis and hemodialysis have not shown significant effect in serum levels.

Councelling-

Obesity- it has a risk associated with it. Ask patient to decrease weight.

Stress reduction

Foods like youghurt, miso, temph could be try.