Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MS2 GI > 10/13- Management of IBD > Flashcards

10/13- Management of IBD Flashcards

1
Q

Goals of IBD Therapy?

A
  • Induce clinical remission
  • Maintain remission
  • Enhance quality of life
  • Avoid long-term toxicity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What types of drugs should be given as severity increases?

A

(Low severity -> high severity)

  • Salicylates
  • Steroids
  • Immunosuppressives
  • Transplant meds
  • Infliximab
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How should flare ups be treated? Remission?

A

Flare:

  • Cyclosporine??
  • New biologics?
  • Anti-adhesion Tx?
  • Anti-TNFs
  • Steroids
  • Salicylates

Remission:

  • Anti-adhesion molecules
  • Anti-TNFs
  • Immunosuppressives
  • Salicylates
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

New goals of therapy? Benefits

A

Mucosal Healing not Clinical Remission

  • Predicts Clinical Remission
  • Fewer hospitalizations, surgeries
  • Prevents Complications of Crohn’s Disease
  • Fewer penetrating complications (fistula, abscess)
  • Less steroid, anti-TNF rx
  • Lower colectomy rates in UC
  • Reduces Risk of Colon Cancer

Possibly Reverse the Natural History

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

New strategies for therapy?

A

Top down vs. bottom up

  • If you flip the pyramid and start with big guns…

Pros:

  • May reverse natural history

Cons:

  • Not everyone may need the big drugs
  • Cost, complications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

In flipped pyramid model, what drugs do you start with? End with?

A

1st level:

  • CyA
  • Infliximab

2nd level:

  • MTX
  • AZA/6-MP
  • Systemic steroids

3rd level:

  • Budesonide
  • Antibiotics
  • 5-ASA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What factors correspond to the risk of progression in CD?

A
  • Smoking
  • Severe initial presentation
  • Perianal disease
  • Extra intestinal manifestations
  • Younger age of onset
  • If steroids required
  • Stricture/penetrating phenotype (compared to inflammatory)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Sustained remission of IBD with therapy STRONGLY depends on what?

A

Adherence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What factors play into adherence?

A

Treatment-Related Factors

  • Dosage/dosing regimen
  • Formulation
  • Cost/reimbursement
  • Adverse effects

Illness-Related Factors

  • Severity, extent, duration of disease
  • Frequency and intensity of flare-ups
  • Complications

Patient-Related Factors

  • Skills/knowledge to follow regimen
  • Belief systems
  • Psychiatric disorders
  • Male gender, nonmarried status
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is Mesalamine?

A

2nd generation (1st gen = Sulfasalazine)

Topical

  • Suppositories
  • Enemas
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe delivery/absorption of Mesalamine?

A
  • Sulfapyridine component prevented from absorption/degradation in proximal GIT (released in proximal colon -> hepatic circulation)
  • 5-ASA portion released in colon to provide therapeutic benefit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Toxicity of 5-ASA vs. Sulfasalazine

  • Why is sulfa still used?
A

Only sulfa:

  • Male infertility
  • Hemolytic anemia
  • Agranulocytosis

Sulfa >> 5-ASA

  • Rash, fever, headache, nausea
  • Dyspepsia
  • Neutropenia
  • Hepatitis

Both:

  • Alveolitis
  • Pancreatitis

5- ASA:

  • Nephritis

Sulfa used because it’s ~ 1/100 the cost

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Systemic corticosteroids can be used to treat IBD.

What forms are used? When? What forms?

A

Oral

  • Indications: moderate/severe ulcerative colitis or Crohn’s disease
  • Preparations: prednisone, prednisolone, budesonide

Parenteral:

  • Indications: severe/toxic ulcerative colitis or Crohn’s disease
  • Preprations: hydrocortisone, methylprednisone, corticotropin (ACTH)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Results/efficacy of corticosteroids in Ulcerative Colitis?

A

At 1 mo:

  • Complete remission (51%)
  • Partial remission (31%)
  • No response (18%)

At 1 yr:

  • Prolonged response without steroids (55%)
  • Steroid dependent (17%)
  • Surgery (21%)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Results/efficacy of corticosteroids in Crohn’s Disease?

A

At 1 mo:

  • Complete remission (5%)
  • Partial remission (26%)
  • No response (16%)

At 1 yr:

  • Prolonged response without steroids (32%)
  • Steroid dependent (28%)
  • Surgery (28%)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Differing opinions in regards to using steroids….

A

Internists- use steroids!

Gastroenterologists- avoid steroids!

  • Complications, side effects
  • Tipping point
  • Exit strategy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are downsides of steroids?

A
  • Osteopenia
  • Infections
  • Hypeglycemia
  • HTN
  • ACNE
  • Moon facies, Buffalo hump
  • Insomnia
  • Mood changes
18
Q

What are some immunosuppressive treatments for IBD?

A
  • 6- mercaptopurine
  • Azathioprine
  • Methotrexate
19
Q

Characteristics of 6-mercaptopurine and azathioprine?

  • Onset
  • Uses
  • ASEs
A
  • Slow onset of action
  • Effective for maintenance and steroid sparing
  • Monitoring enzyme activity
  • Monitoring drug levels

ASEs:

  • Allergic reaction
  • GI disturbances
  • Hepatotoxicity
  • Infection
  • Pancreatitis
  • Bone marrow suppression
  • Malignancy/lymphoma (?)
20
Q

Characteristics of Methotrexate?

  • Onset
  • Uses
  • Form
A
  • Faster acting than 6MP/Azathioprine
  • Maintenance therapy for Crohn’s disease
  • Only parenteral rx is proven effective
21
Q

What is the AZA metabolite pathway? Significance?

A

AZA -> 6MP

  • Some portion of the population is missing a critical enzyme (?)
  • May wipe out bone marrow
22
Q

What are biologics?

Examples of some used for IBD?

A

Monoclonal Antibodies Anti-TNFs:

  • Infliximab (CD and UC)
  • Adalimumab (CD and UC)
  • Certolizumab (CD)
  • Golilumumab (UC)

Anti-interleukin 12/23

  • Ustekinumab (CD)

Anti-integrins

  • Natalizumab
  • Vedolizumab
23
Q

Uses of Anti-TNFs?

  • Downsides
  • Examples
A

Effective in Treating Flares

  • May Maintain Remission
  • Treats Fulminant Colitis (= cyclosporine) and Crohn’s disease

Downsides

  • Cost
  • Side Effects

Examples:

  • Infliximab (CD and UC)
  • Adalimumab (CD and UC)
  • Certolizumab (CD)
  • Golilumumab (UC)
24
Q

Adverse effects of biologics?

A
  • Autoimmunity, immunogenicity
  • Congestive heart failure
  • Hepatotoxicity
  • Malignancy/lymphoma (?)
  • Demyelinating disease, PML
  • Infection (TB, histo, granulomatous diseases…)
  • BM suppression
  • Infusion reactions, injection site reactions
25
Q

How well do anti-TNFs work? Compared to AZA? Combo?

A

Combo was best for remission

  • Infliximab + AZA => 57% remission
  • Infliximab alone => 44% remission
  • AZA alone => 31% remission

Combo was best for mucosal healing

  • Infliximab + AZA => 44% healing
  • Infliximab alone => 30% healing
  • AZA alone => 17% healing
26
Q

What is the theory behind using anti-adhesion therapies for IBD? List the meds used

A

Prevent firm adhesion/diapedesis of WBCs to control inflammation involved in IBD (anti-integrin)

Meds used:

  • Natalizumab
  • Vedolizumab
  • Etrolizumab
27
Q

What are the significant adhesion molecules being targeted?

A

CNS: a4B1 integrin

  • VCAM-1

Gut: a4B7 integrin

  • MadCAM-1
28
Q

The following agents work on what integrin targets?

GI specific? PML risk?

  • Natalizumab
  • Vedolizumab
  • Etrolizumab
  • PF-00547659
A
29
Q

What are surgical options in ulcerative colitis?

A

Colectomy cures UC!

  • Brooke ileostomy
  • Koch ileostomy: make pouch with continent ileostomy (drain pouch a few times a day; no bag)
  • J pouch: functions as new rectum (most common now) (but people don’t always like this option)

Alternatives:

  • Conventional ileostomy
  • Continent ileostomy
  • Ileo-anal anastamosis with J-pouch

Save lives… not colons

30
Q

Weighing medical therapy vs. surgery risks

A

Medical therapy:

  • Serious infection
  • Lymphoma
  • Bone marrow suppression
  • Other toxicities: hepatic, neurologic, cardiac

Surgery:

  • Postsurgical complications: anastamotic leak, cuffitis, bowel obstructions, fistulas, Crohn’s disease, pelvic sepsis
  • Reoperation
  • Pouchitis
  • Reduced fecundity/fertility

Key point: both have risks

31
Q

What are surgical options in Crohn’s disease?

A
  • NOT curative (unlike ulcerative colitis)
  • Specific goals:
  • Obstruction
  • Abscess
  • Medical failure
  • Recurrence usually at anastamosis
32
Q

What are big risks of therapy with Mesalamine, steroids, immunomodulators, and biologics?

A
  • Infection
  • Lymphoma (HSTCL)
33
Q

Increased risk of lymphoma with what patient characteristics?

A
  • Age
  • Males
  • IBD history
34
Q

Increased risk of Hepatosplenic T-cell lymphoma with what patient characteristics?

Prognosis?

A
  • Almost always in young males
  • Usually fatal
35
Q

What IBD treatment has the highest risk for infection?

A

(Most -> Least)

  • Infliximab, 4.4RR (Histo)
  • IMM, 3.8RR (Herpes)
  • Steroids, 3.3RR (Candida)
  • ASA (1.0 risk ratio)

Corticosteroid use is higher than all of these, and narcotic analgesics are even higher

36
Q

What is mortality risk of Crohn’s disease?

A

1.5

37
Q

What is omission bias?

A

People tend to worry more about a low risk of harm from something they do than a higher risk of harm from doing nothing (think vaccinations)

38
Q

What is the risk of developing Non-Hodgkin’s Lymphoma in a patient with Crohn’s disease?

  • What about if the pt receives 6MP or Azathioprine?
  • What about receiving combo anti-TNF and immunomodulator?
A
  • 2/10,000 treated patients annually
  • 4/10,000 treated patients annually receiving 6MP or Azathioprine
  • 6/10,000 treated patients annually receiving combo anti-TNF and immunomodulator
39
Q

What is the risk of developing PML with Natalizumab?

A
  • 10/10,000 pts with Crohn’s disease and/or MS
40
Q

Characteristics of different IBD drugs:

  • Acute vs. Long term
  • Safety
  • Mucosal healing

FOR

  • ASA
  • Steroid
  • 6MP/AZA/mtx - Mabs
A
41
Q

What is the role of nutritional therapy in IBD?

  • When to use
  • Alternatives
A

Nutrition support as proven therapy

  • TPN may suppress symptoms, but relaps occurs upon refeeding
  • EN is less effective than glucocorticosteroids

Treat with EN or TPN if:

  • “Malnourished” and cannot maintain oral intake
  • Short bowel syndrome unable to maintain fluid/energy balance
  • Growth failure

Limited goals and benefits for both TPN and EN (enteral nutrition)

Alternative/Complementary rx is common in IBD patients

  • Most evidence for circumin, from the turmeric plant (think curries)
  • Marijuana

MS2 GI (26 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions