AY 2023 Sem 1 A371 IS05 Lecture - Student

OFFICIAL (CLOSED) \ NON-SENSITIVE
A371 Pharmacotherapy and Pharmacy Practice

Lesson 5: Nausea, vomiting and gastric
disorders
Activity Owner: Ho Sz Ting

Approved By: Dawn Er
Module Chair: Ho Sz Ting
COPYRIGHT © 2023 BY REPUBLIC POLYTECHNIC, SINGAPORE 1

Definition of Terms
Nausea: An unpleasant sensation associate with vague epigastric and abdominal symptoms, and
usually comes before vomiting.
Regurgitation: Reverse transit of stomach contents into the pharynx that stops short of vomiting.
Retching: A strong, involuntary and unsuccessful effort to vomit.
Vomiting: The physical expulsion of stomach, oesophageal and oropharyngeal contents.
Emesis: The action or process of vomiting.

In this segment, you will learn the following about

nausea and vomiting:
• Physiology
• Causes
• Complications
• When to refer to a doctor
• Pharmacological management
• Non-pharmacological management

Vomiting process
Control Centers:
• Vomiting Center(VC)
• Chemoreceptor
Trigger Zone (CTZ)
Neurotransmitters:
• Acetylcholine
• Serotonin
• Dopamine
• Histamine
• Substance P
Watch a video on vomiting reflex at your own time:

https://www.youtube.com/watch?v=GSHTLWbwKgo
Causes of Nausea and Vomiting

• Peptic ulcer disease • Anorexia or bulimia
• Small intestinal obstruction • Motion sickness
• Irritable bowel syndrome • Brain tumours
• Appendicitis • Brain infections
• Viral gastroenteritis • Migraine
• Intake of alcohol, NSAIDs, • Intake of anti-cancer drugs
antibiotics
• Pregnancy
• Overeating

Complications of Nausea & Vomiting

Major concerns
Dehydration
Laceration
causing Electrolyte
blood in imbalances
vomit
Complications
Malnutrition Aspiration
6
COPYRIGHT © 2023 BY REPUBLIC POLYTECHNIC, SINGAPORE
Activity 1: Recall from Lesson 1

Which of the following are symptoms dehydration in an adult?

Treatment of Nausea and Vomiting

Treatment goals: Identify and correct the underlying cause.
Pharmacological and/or non-pharmacological therapies may be used depending on the
causes.
Causes of vomiting Pharmacological therapy Non-pharmacological
therapy
Viral gastroenteritis/ √ √
food poisoning
Motion sickness √ √
Morning sickness in pregnancy √ √
Chemotherapy √

When to refer an adult patient to a doctor
Adult patients should be referred to a doctor if vomiting occurs for more than one day, if diarrhea
and vomiting last more than 24 hours, and if there are signs of moderate dehydration.
Patients should be referred to a doctor immediately if the following signs or symptoms occur:
• Severe headache or stiff neck

• Lethargy These symptoms are likely caused by brain disorders
• Confusion
• Decreased alertness
• Blood in the vomit ("coffee grounds" appearance) These symptoms may be caused by a
• Severe abdominal pain gastric ulcer bleeding
• Vomiting with fever over 38.5oC These increase the risk of dehydration
• Vomiting and diarrhea are both present
• Rapid breathing or pulse

When to refer a child patient to a doctor
An infant or a child under 6 years old should be referred to the doctor if:
• Vomiting lasts more than a few hours
• Diarrhea is also present
• Signs of dehydration occur
• There is a fever higher than 38.5oC
• The child has not urinated for six hours
A child over 6 years old should be referred to the doctor if:

• Vomiting lasts one day
• Diarrhea AND vomiting lasts for more than 24 hours
• Signs of dehydration occur
• There is a fever higher than 38.5oC
• The child has not urinated for six hours

Non-Pharmacologic Advice to Prevent

Nausea and Vomiting in Pregnancy
Acupressure point P6 or Nei Guan point

Non-Pharmacologic Advice to Prevent Nausea

and Vomiting caused by motion sickness
Acupressure point P6 or Nei Guan point

Activity 2: Discussion
Scenario:
You are a pharmacy technician and the pharmacist is currently out for her lunch break.
A mother comes along to look for a medicine to help reduce her 18-month-old child’s
vomiting. Her child is vomiting after every feed. She looks lethargic and has sunken
eyes and cheeks.
How would you advise the mother?

Commonly Used Antiemetic drugs
Pharmacological Classes:
1. Dopamine receptor antagonist
2. Antihistamine (only specific antihistamines)
3. Selective 5HT3-receptor antagonist

Dopamine receptor antagonist

- Domperidone
MOA: It blocks the dopamine receptors in the peripheral areas and does not readily cross the blood-brain
barrier.
It increases oesophageal peristalsis and increases lower oesophageal sphincter pressure, increases gastric
motility and peristalsis, and enhances gastroduodenal coordination, therefore, facilitating gastric emptying
and decreasing small bowel transit time.
Indications Common range of Side effects Contraindications Special counselling points

dosing
Relief of nausea Adult: PO 10mg 3 Dry mouth Hypersensitivity to Take 15 to 30 minutes before food.
and vomiting times a day; max domperidone, Heart
30mg/day failure Avoid taking grapefruit or grapefruit juice
during the therapy.
Child: PO 0.25mg/kg
3 times daily; max Do not exceed 30mg per day as it may
10mg/day cause irregular heartbeat leading to fainting

Dopamine receptor antagonist -

Metoclopramide
MOA: It blocks dopamine receptors so it enhances motility in upper GI tract and
accelerates gastric emptying; increases lower oesophageal sphincter tone.
Indications Common range of Side effects Contraindications Special counselling

dosing points
Relief of nausea and PO Adult: 10mg TDS; Drowsiness Hypersensitivity to Take 30 minutes before
vomiting max 30mg/day metoclopramide food.
This medicine may

affect mental alertness
and/ or coordination. If
affected do not drive or
operate machinery.
May be used in pregnancy.

Dopamine receptor antagonist -

Prochlorperazine maleate
MOA: It blocks dopaminergic D1 and D2 receptors in the brain, including the
chemoreceptor trigger zone

dosing points
Relief of nausea and PO 5-10mg 3-4 times Constipation, dry mouth, Hypersensitivity to This medication may cause
vomiting daily; max 40mg/day drowsiness phenothiazines drowsiness. If affected, do
not drive or operate
machinery.
Do not drink alcohol.
This medicine may cause

dizziness especially when
you stand up quickly.

Antihistamine - Cinnarizine
MOA: It acts by interfering with the signal transmission between vestibular apparatus of the inner
ear and the vomiting center of the hypothalamus.

dosing points
Motion sickness PO 25mg at least half Drowsiness (children Hypersensitivity to This medicine may
an hour before and elderly are more cinnarizine make you sleepy. If
travelling; to be susceptible), GI this happens, do not
repeated every 6 discomfort drive or use tools or
hours. machines.

Antihistamine - Dimenhydrinate
MOA: It blocks chemoreceptor trigger zone, diminishes vestibular stimulation, and depresses
labyrinthine function through its central anticholinergic activity.
Indications Common range of dosing Side effects Contraindications Special counselling points
Motion Adult: Drowsiness, Hypersensitivity to This medicine may make you

sickness, PO 50-100 mg every 4-6 hours. Max: 400 dizziness, dry dimenhydrinate sleepy. If this happens, do not drive
nausea and mg/day. mouth or use tools or machines.
vomiting
Child 6-12 yo: Do not drink alcohol.
PO 25 to 50mg every 6-8 hours. Max:
150mg/day
Child 2-5 yo:

PO 12.5 to 25mg every 6-8 hours. Max:
75mg/day
For prevention of motion sickness, give the

1st dose 30-60 mins before travelling.

Antihistamine - Promethazine
dosing points
- nausea & vomiting Adult: Drowsiness, dizziness, Hypersensitivity Take with food, water, or
dry eyes, nausea/ promethazine, other milk to decrease GI
PO 12.5 to 25 mg
vomiting, dry mouth, phenothiazines, discomfort.
every 4 to 6 hours as
Other indications: urinary retention asthma; children <2
needed.
years of age
- allergy / urticaria
This medicine may
make you sleepy. If this
Child:
happens, do not drive or
0.25 to 0.5 mg/kg/dose use tools or machines.
every 4 to 6 hours as
needed

Selective 5HT3-receptor antagonist

- Ondansetron
MOA: It blocks 5HT3 receptors in gastrointestinal tract and in the chemoreceptor trigger
zone of the brain.
Indications Common range of dosing Side effects Contraindications Special counselling

points
Treatment of nausea PO 8 mg taken 1 to 2 hours Constipation, fatigue, Hypersensitivity to If you vomit within 1
and vomiting induced by before chemotherapy or headache, malaise ondansetron hour of taking your first
chemotherapy or radiation treatment, followed by tablet, take the same
radiotherapy, 8 mg orally every 12 hours later dose again. If you
for a maximum of 5 days continue to vomit,
consult your doctor.
Prevention of PO 8 mg given as a single
postoperative nausea dose 30-60 mins before
and vomiting surgery

HSA classifications of the antiemetics

Drug HSA classification
Domperidone POM (with exemptions for supply without prescription)
Max daily dose: 30mg
Max supply: 14 days
It means the Prescription
Min age: 12 years old Only Medicines (POM)
have certain criteria to be
met (known as
Metocloperamide Prescription Only medicine
exemptions) before the
pharmacist can supply
Prochlorperazine Prescription Only medicine
without a prescription.
Cinnarizine Pharmacy Only medicine
Dimenhydrinate Pharmacy Only medicine
Ondansetron Prescription Only medicine

Activity 3
Scenario 1:
Pamela, 4 years old, is experiencing nausea and vomiting. She vomited twice with a body
temperature of 37.6oC. She has no other symptoms.
Pamela’s mother wants to purchase domperidone from the pharmacist.
Explain why it is inappropriate for the pharmacist to dispense domperidone syrup to her.

Activity 3 (continued)
Scenario 2:
Mr Tan comes to the pharmacy with a prescription for
metoclopramide.
Double check whether the dosing regimen is appropriate.
Discuss the actions that should be taken by the PT and

how Mr Tan should be counselled on the use of the
medicine.

Drug-related problems (DRPs) to look out for

Category of DRP DRP Term
Indication Therapeutic duplication
Drug selection Contraindication
Inappropriate drug selection
Inappropriate drug formulation/ dosage form
Dosage regimen Dosage too high
Dosage too low
Inappropriate frequency OR
Inappropriate route/ site (without change in daily dose)
Duration too long
Duration too short
Drug interactions Drug-drug interaction
For further reading:

https://www.moh.gov.sg/docs/librariesprovider4/default-document-library/pharm_tech_etp_competency_stds_ig_vsep20.pdf

Peptic Ulcer Disease and other gastric disorders
In this segment, you will learn the following about

Gastroesophageal Reflux Disease, Gastritis and
Peptic Ulcer Disease:
• Physiology
• Causes
• Complications
• When to refer to a doctor
• Pharmacological treatment
• Non-pharmacological management

Gastroesophageal Reflux Disease (GERD)
Pathophysiology:
GERD occurs when stomach acid back flows up into the
oesophagus.
Normally, the lower oesophageal sphincter (LES) prevents reflux

of stomach contents.
However, in patients with GERD, the LES relaxes abnormally or

weakens hence allowing stomach acid to flow back up into the
oesophagus to irritate the mucosa of the oesophagus.
The extent of symptoms and of mucosal injury is proportional to

the frequency of reflux events, the duration of mucosal
acidification, and the caustic potency of refluxed fluid.

Signs and Symptoms of GERD

Typical symptoms:
Heartburn: Burning sensation in the chest, usually after eating, which might be
worse at night
Pain may radiate up into the chest, into the back or sometimes into the throat or
neck
Dysphagia (difficulty swallowing)
Sensation of an object in the throat
Regurgitation without nausea
Atypical symptoms:
Chest pain that may radiate into neck or arm (may be confused with angina or
heart attack)
Chronic cough
Non-allergic asthma (caused by aspiration of refluxed material into upper
airways and lungs)
Laryngitis, pharyngitis, hoarseness of voice

Risk factors for GERD

Conditions that can increase the risk of GERD:
• Obesity
• Pregnancy
• Connective tissue disorders such as scleroderma
• Bulging of the top of the stomach up into the diaphragm (hiatal hernia)
• Delayed gastric emptying
Factors that can aggravate acid reflux:

• Body position - supine
• Smoking Reduced
• Eating large meals or eating late at night tone of LES
• Eating chocolate, peppermint, high-fat food
• Drinking alcohol or drinks with caffeine
• Drugs such as opioids, aspirin, etc.
• Wearing tight-fitting clothes  increases gastric pressure

Tips to prevent GERD or heartburn

If possible, avoid taking aspirin or NSAIDs
Do not wear tight-fitting clothing
Eat smaller meals
Do not lie down for about 3 hours after eating
Elevate the head of bed if symptoms occur at night
Avoid smoking, caffeine, alcohol and foods that exacerbate
symptoms of heartburn

When to refer patient to doctor

Symptoms persisting more than two weeks despite self-treatment
Symptoms of > 3 months of duration, regardless of whether patients are self-treated
Presence of symptoms which are moderate or severe, occurring 3 times per week with
significant impact on quality of life.
Refractory GERD
Taking more than one course of PPI treatment every four months
Children in whom the use of antacids are not indicated and/or require the use of H2RAs
or PPIs
Above 40 years old and experiencing GERD symptoms for the first time
Having alarm symptoms like:
 Hoarseness, wheezing, shortness of breath, enamel erosion and otitis media
 Swallowing difficulty, pain on swallowing, chest pain, vomiting, involuntary weight loss
and jaundice
 Fever, headache, nausea or vomiting (especially with coffee-ground) with heartburn
 Signs of GI bleeding (e.g. black tarry stools or vomiting of blood)

Activity 4
A lady is browsing the over-the-counter section and looking at the antacid products.
You approach her to ask whether she needs any help.
She tells you that she has a burning sensation in the chest even though she did not
eat any spicy food.
She often has regurgitation after her meals for the past 1 week.
How would you handle this query? Should she self-medicate?

Commonly Used Drugs for GERD / Heartburn

Pharmacological Classes:
1. Antacids
2. Alginate
3. Antiflatulent (only for gas retention in stomach/bloatedness)
4. H2 receptor antagonists (H2RA)
5. Proton pump inhibitors (PPI)

Antacids
MOA: “Anti-acid” - Neutralise the excess gastric acid that is already
produced in the stomach
Bases containing:
Acid
◦ Aluminium
◦ Magnesium
◦ Calcium
◦ Sodium (bicarbonates)

Aluminium hydroxide
GSL

dosing points
Dyspepsia PO 5-10ml 4 times Constipation N/A Taken after meals and
GERD daily (after meals and at bedtime
at bedtime) when
needed Not to be taken at the
same time as other
drugs since this drug
may impair absorption
or damage enteric
coatings designed to
prevent dissolution in
the stomach

Magnesium carbonate
GSL
Indications Common range of Side effects Contraindications Special

dosing counselling points
Dyspepsia PO 10ml 3 times daily Diarrhoea (dose Severe renal failure Taken after meals and
GERD between meals or dependent), belching at bedtime
when required due to liberated
carbon dioxide Not to be taken at the
same time as other
drugs since this drug
may impair absorption
or damage enteric
coatings designed to
prevent dissolution in
the stomach

Magnesium trisilicate
GSL

dosing points
Dyspepsia PO 5-15ml 3 times Diarrhoea, Severe renal failure Taken after meals and at
GERD daily between meals or belching due to bedtime
when required liberated carbon
dioxide Not to be taken at the
same time as other drugs
since this drug may impair
absorption or damage
enteric coatings designed
to prevent dissolution in
the stomach

Food for thought!
Why are aluminium hydroxide and magnesium carbonate

often found together in combination antacid products?

Watch this video to see how it works:

https://youtu.be/OtCzah_56qc
Gaviscon® GSL
Indications Common range Side effects Contraindications Special counselling

of dosing points
Sodium alginate Mild symptoms PO 10 - 20ml Diarrhoea, Severe renal failure Chew tablets before
with calcium of gastro- (liquid) or 2-4 tabs belching due to swallowing.
carbonate and
oesophageal up to 4 times daily liberated carbon Taken after meals and at
sodium
bicarbonate reflux disease (after meals and dioxide bedtime
at bedtime) or
when required Not to be taken at the
same time as other drugs
since this drug may impair
Calcium carbonate and sodium bicarbonate act as the absorption or damage
antacids. Sodium alginate creates a raft on top of the enteric coatings designed
gastric contents preventing reflux into the oesophagus. to prevent dissolution in
the stomach

Simethicone for gas retention
GSL
MOA: It is a mixture of silicon polymers and is used as a de-foaming agent which allows gas bubbles
in the stomach and intestines to come together more easily. This allows for easier passage of gas.

dosing points
Gas retention, PO 40-125mg QDS PRN NIL NIL Take with or after each
bloating Max: 500mg/day feed/ meal.
(Follow product
instructions)

MOA of drugs that reduce gastric acid production
Both H2 receptor antagonist and Proton Pump

Inhibitor work on the parietal cells which are in
charge of producing the gastric acid.
The H2 receptor antagonist competitively block H 2

receptors on parietal cells, reducing gastric acid
secretion.
Example: Famotidine
The proton pump inhibitor irreversibly inactivate the

hydrogen/ potassium ATPase enzyme system (proton
pumps), suppressing both stimulated and basal acid
secretion. When the PPI is stopped, acid secretion is
restored by synthesis of new hydrogen/ potassium ATPase.
Example: Omeprazole and Esomeprazole
Source: Olbe L, Carlsson E, Lindberg P. A proton-pump inhibitor expedition: the case histories of
omeprazole and esomeprazole. Nat Rev Drug Discov. 2003;2:132-9

H2-receptor antagonist –
Famotidine
dosing
GERD PO 20 mg up to twice Headache, Hypersensitivity to Administer without regard to
daily when needed constipation, famotidine meals. May administer with
(max 40 mg/day) diarrhoea, dizziness antacids.
It may also be taken 10 to

60 minutes before meals or
beverages that cause
heartburn.
It should not be taken for

longer than 2 weeks without
consulting a doctor.

Proton Pump Inhibitor –

Omeprazole
Indications Common range of Side effects Contraindicatio Special counselling points
dosing ns
GERD, Peptic GERD: PO 20mg OD for 4 Headache, Hypersensitivity to Administer 30 to 60 minutes before a meal;
Ulcer Disease, -8 weeks, continued for a Abdominal pain, omeprazole or best if taken before breakfast.
Helicobacter pylori further 4-8 weeks if not diarrhoea, esomeprazole
eradication fully healed; discontinue flatulence, nausea, Tablet should be swallowed whole with a full
once asymptomatic vomiting, glass of water before breakfast. Do not chew
constipation, skin or crush.
NSAID-associated PUD: rash
PO 20-40mg OD for 4-8 Capsule may be opened and contents mixed
weeks with 1 tablespoon of applesauce (soft
enough to swallow without chewing).
Eradication of Helicobacter Swallow immediately with a glass of cool
pylori infection with water; mixture should not be chewed,
antibiotics: PO 20mg BD crushed, warmed, or saved for future use.

Proton Pump Inhibitor –

Esomeprazole

dosing
GERD, Peptic GERD: PO 20 mg once daily Headache, Hypersensitivity to Capsule: Swallow whole and take at least 1
Ulcer Disease, for 14 days (maximum: 20 Abdominal pain, esomeprazole or hour before eating (best if taken before
Helicobacter pylori mg/day); treatment may be diarrhoea, omeprazole breakfast).
eradication repeated after 4 months if flatulence, Capsule can be opened and contents
needed. nausea, vomiting, mixed with 1 tablespoon of applesauce.
constipation, Swallow immediately; mixture should not be
NSAID-associated PUD: PO chewed or warmed
20mg OD for 4-8 weeks
Tablet: Swallow whole; do not crush or
Eradication of Helicobacter chew; administer with a full glass of water
pylori infection with before breakfast in the morning.
antibiotics: PO 20mg BD

HSA classifications of antisecretory drugs

Drug HSA classification
Famotidine POM (with exemptions for supply without prescription)

Indications: Short-term relief of heartburn, dyspepsia and hyperacidity.
Maximum Daily Dose: 20 mg
Maximum Supply: Up to 2 weeks' duration
Omeprazole POM (with exemptions for supply without prescription)

Indication: Relief of heartburn symptoms associated with acid reflux
Maximum daily dose: 20mg
Maximum supply: 2 weeks
Minimum age: 18 years
Pharmacy Only – Zenpro®, Promesec® and Omesec® brands only
Esomeprazole POM (with exemptions for supply without prescription)

Indication: Relief of heartburn symptoms associated with acid reflux
Maximum daily dose: 20mg
Maximum supply: 2 weeks
Minimum age: 18 years

Further reading:
Omeprazole vs Esomeprazole
Omeprazole Esomeprazole
Consists of racemic mixture of R- and S- Consists of S- isomer of Omeprazole
isomers of Omeprazole
Pro-drug which is converted in the parietal Active drug

cells of the stomach to active drug
Lower activity in inhibiting the proton pump Greater activity in inhibiting the proton pump
Cheaper More expensive

Activity 5
Refer back to scenario in Activity 4.
The lady tells you that she has a burning sensation in the chest even though she did not eat any
spicy food.
She often has regurgitation after her meals for the past week. And we have decided that it is safe
for her to self-medicate.
Out of the drugs that you have learnt so far, which one will you recommend to her?
Explain your choice(s).
What other advice would you give her?

Gastritis
Inflammation of the gastric lining
It may occur suddenly (acute gastritis), or appear slowly over

time (chronic gastritis).
Increased risk of developing gastric ulcers, stomach cancer.
Signs and symptoms:

• Gnawing or burning ache or pain in your upper abdomen that
may become either worse or better with eating
• Nausea
• Vomiting Source: https://www.epainassist.com/abdominal-pain/stomach/gastritis
• A feeling of fullness in your upper abdomen after eating
Gastritis does not always cause signs and symptoms.
Treatment is usually with a PPI over 4-8 weeks.

Comparing GERD, PUD & gastritis

GERD PUD Gastritis
Signs & • Heartburn • Gnawing or burning • Gnawing or burning ache

Symptoms • Regurgitation epigastric pain or pain (indigestion) in
• Difficulty in swallowing • Feeling of abdominal your upper abdomen that
• Pain when swallowing fullness or bloating may become either
• Chest pain • Awakened with pain at worse or better with
• Chronic cough night eating
• Asthma • Anorexia, dizziness, • Nausea
• Laryngitis weakness (in patients of • Vomiting
• Hoarseness advanced age) • A feeling of fullness in
• May cause bleeding in your upper abdomen
stomach after eating
Main focus: GERD and PUD
Adapted from Handbook of Nonprescription Drugs, Fourteenth edition, Chapter 5, page 322

Peptic Ulcer Disease (PUD)

Ulcers typically extend deeper into the muscularis mucosa
3 common forms of peptic ulcers:

• Stress ulcer
• Nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers
• Helicobacter pylori-associated ulcers
Tips for patients with peptic ulcers:

• Avoid taking NSAID until ulcer is confirmed healed.
• Avoid drinking alcohol.
• Stop smoking.
• Practise stress management.
• Avoid food that may aggravate peptic ulcers, like spicy food,
caffeine, chocolate and acidic food like tomatoes, citrus fruits.

NSAID-induced ulcers
Patients at high risk of developing gastrointestinal complications with a NSAID include:
• Age > 65 years old
• History of peptic ulcer disease or serious GI complication
• Taking other medicines that increase the risk of GI side effects
• With serious co-morbidity (e.g. cardiovascular disease, diabetes, renal or hepatic impairment)
The risk of serious upper GI side effects varies between individual NSAIDs.
Whenever possible, NSAID should be stopped if an ulcer occurs.
Treatment is usually with a PPI for 4-8 weeks.
In those with a history of upper GI bleeding or with 3 or more risk factors for GI ulceration, a
combination of cyclo-oxygenase-2 selective inhibitor (COX-2 inhibitor) with a PPI may be more
appropriate.
Recap on how NSAIDs may cause GI side effects

Helicobacter pylori-associated ulcers
• Helicobacter pylori is a spiral-shaped, pH-sensitive,

gram-negative bacterium.
• It produces large amounts of urease which hydrolyses

urea in the gastric juice and converts it to ammonia and
carbon dioxide.
• The local buffering effect of ammonia (weak base)

protects this bacteria and allows it to survive in acidic
conditions.

Helicobacter pylori infection link to PUD

• Helicobacter pylori infection increases the risk
of gastritis and peptic ulcers.
• When a person with gastric ulcer is diagnosed

with Helicobacter pylori infection, the priority is
to eradicate the bacteria and clear the
infection.
• Eradication of Helicobacter pylori reduces

recurrence of gastric and duodenal ulcers and
reduces the risk of re-bleeding.
• The presence of Helicobacter pylori should be

confirmed before starting eradication
treatment.

Helicobacter pylori eradication

• Acid inhibition combined with antibacterial treatment is highly effective in the eradication of
Helicobacter pylori.
• Therefore, Helicobacter pylori infection must be treated with a combination of three drugs
(i.e. 2 antibiotics and 1 proton pump inhibitor)
 PPI + Amoxcillin + Clarithromycin (most commonly used)
 PPI + Clarithromycin + Metronidazole (for patients with penicillin allergy)
• This is commonly known as the triple therapy.

• May be prescribed for 1 – 2 weeks
• These regimens eradicate Helicobacter pylori in about 85% of cases.
• Treatment failure usually indicates antibiotic resistance or poor compliance.

Helicobacter pylori eradication triple therapy

Duration range from 1-2 weeks. 2-week
Possible combinations: treatment is recommended for higher cure rate.
PPI Amoxicillin Clarithromycin Metronidazole
Omeprazole 20mg
Combo 1 1g BD 500mg BD -
Most commonly
BD prescribed combination
Omeprazole 20mg
Combo 2 500mg TDS - 400mg TDS
BD
Omeprazole 20mg
Combo 3 - 500mg BD 400mg BD
BD
Esomeprazole
Combo 4 1g BD 500mg BD -
20mg BD
Esomeprazole
Combo 5 - 500mg BD 400mg BD
20mg BD

Helicobacter pylori eradication quadruple therapy

Quadruple Therapy for 2 weeks What is the replacement
PPI + Bismuth + Tetracycline + Metronidazole antibiotic if tetracycline
is not available?
Hint: Check UpToDate
• This regimen is used when there is eradication failure.
o Eradication failure: Patient still has H. pylori infection despite taking triple therapy.
• Treatment failure usually indicates antibiotic resistance or poor compliance.

Amoxicillin
Clarithromycin
Antibiotics
• These are only prescribed for Helicobacter pylori-induced
Prescription Only
Metronidazole
ulcers. Medicine
Tetracycline
• Not to be prescribed for NSAID-induced ulcers.
General counselling points:

Take with or just after food, or a meal.
Space the doses evenly throughout the day.
Keep taking this medicine until the course is finished, unless you are told to stop.
If rash occurs, discontinue treatment.
Specific counselling point for metronidazole:

Do not drink alcoholic beverages as it may cause disulfiram-like reaction (severe flushing, n/v, throbbing
headache, dizziness, etc.)
Specific counselling points for tetracycline:

Do not take milk, indigestion remedies, or medicines containing iron, zinc, 2hours before or after you take this
medicine.
Take this medicine when your stomach is empty. This means an hour before food or 2 hours after food.

Gastroprotective complexes and chelators (MOA)

*For further reading*
Bismuth subcitrate helps to heal ulcers.

• In the gastric environment, it stimulates the prostaglandin PGE2 production and leads to mucus and
bicarbonate secretion.
• Along with mucus, it forms a glycoprotein bismuth complex which coats the ulcer and acts as a
diffusion barrier for hydrochloric acid.
• May also have antibacterial effects against Helicobacter pylori.
Sucralfate also helps to heal ulcers.

• It forms a complex by binding with positively charged proteins in exudates, forming a viscous paste-
like, adhesive substance.
• This selectively forms a protective coating that acts locally to protect the gastric lining against peptic
acid, pepsin, and bile salts.
• It may be given for prevention of stress-induced ulcers.

Bismuth subcitrate POM
Indications Common range Side effects Contraindications Special counselling points

of dosing
Eradication of PO 120mg QDS for May darken teeth Hypersensitivity to Chew the tablets before swallowing
Helicobacter 2 weeks and tongue and bismuth with half a glass of water
pylori infection blacken faeces
(generally Take on empty stomach (30 mins
reversible within before breakfast, midday meal and
several days after main evening meal and 2 hours after
treatment is main evening meal)
discontinued)
Milk should not be drunk by itself during
treatment but small quantities may be
taken in tea or coffee or on cereal
Antacids, fruit, or fruit juice should not

be taken half an hour before or after a
dose

Sucralfate GSL

dosing points
Benign gastric and PO 1 g 4 times daily Constipation Hypersensitivity to Administer on an empty
duodenal ulceration for 4 to 8 weeks sucralfate stomach.
Maintenance therapy: Do not administer antacids

PO 1 g twice daily. within 30 minutes of
administration of sucralfate.
In general, separate
administration of other oral
medications and sucralfate
by at least 2 hours.

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OFFICIAL (CLOSED) \ NON-SENSITIVE

A371 Pharmacotherapy and Pharmacy Practice

Activity Owner: Ho Sz Ting

COPYRIGHT © 2023 BY REPUBLIC POLYTECHNIC, SINGAPORE 1

Retching: A strong, involuntary and unsuccessful effort to vomit.

Vomiting: The physical expulsion of stomach, oesophageal and oropharyngeal contents.

Emesis: The action or process of vomiting.

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In this segment, you will learn the following about

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Watch a video on vomiting reflex at your own time:

Causes of Nausea and Vomiting

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Complications of Nausea & Vomiting

Activity 1: Recall from Lesson 1

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Treatment of Nausea and Vomiting

Morning sickness in pregnancy √ √

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When to refer an adult patient to a doctor

• Severe headache or stiff neck

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When to refer a child patient to a doctor

A child over 6 years old should be referred to the doctor if:

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Non-Pharmacologic Advice to Prevent

Acupressure point P6 or Nei Guan point

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Non-Pharmacologic Advice to Prevent Nausea

Acupressure point P6 or Nei Guan point

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Commonly Used Antiemetic drugs

3. Selective 5HT3-receptor antagonist

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Dopamine receptor antagonist

Indications Common range of Side effects Contraindications Special counselling points

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Dopamine receptor antagonist -

Indications Common range of Side effects Contraindications Special counselling

This medicine may

May be used in pregnancy.

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Dopamine receptor antagonist -

Indications Common range of Side effects Contraindications Special counselling

Do not drink alcohol.

This medicine may cause

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Indications Common range of Side effects Contraindications Special counselling

Do not drink alcohol.

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Motion Adult: Drowsiness, Hypersensitivity to This medicine may make you

Child 2-5 yo:

For prevention of motion sickness, give the

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Selective 5HT3-receptor antagonist

Indications Common range of dosing Side effects Contraindications Special counselling

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HSA classifications of the antiemetics