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PDAT4 > 29/30 - IBD > Flashcards

29/30 - IBD Flashcards

1
Q

IBD Risk Factors

Protective Effects

A

HIGH FIBER DIET

  • *HYGIENE**
  • *Larger Family** / # of siblings / living on FARM / PET exposure

Smoking / Apendectomy
only for UC

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2
Q

Which IBD based on Risk Factor?

SMOKING = PROTECTIVE

APENDECTOMY = Protective

A

UC

UC = Smoking / Apendectomy is GOOD

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3
Q

IBD
Risk Factors

A

NSAIDS / ORAL CONTRACEPTIVES

Sedentary Lifestyle

Stress –> gut inflammation

VITAMIN D Deficiency

Allergy to cow milk / high refined sugar intake

Poor Sleep Quality –> inflmamation

Dysbiosis luminal MICROBIOTA

10-25% have Family History

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4
Q

IBD Diagnosis

PHYSICAL EXAM

A

ENDOSCOPY** + **BIOPSY
GOLD STANDARD for Diagnosing IBD

Colonoscopy (5ft) / Sigmoidoscopy (2ft)

EGD = CD only
Esophagogastroduodenoscopy, doesnt include Jejunum/ileum

Wireless Video Capsule
visualize small bowel,gets STUCK, not used often

Imaging Studies = CT Scan / MRE
evaluates the upper GI tract

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5
Q

Ulcerative Colitis Differences

Disease Location

Endoscopic Visualization

Pathalogy

A

Disease Location
confined to JUST THE COLON (okay for EGD)

Endoscopic Visualization

  • *Diffuse Superficial Inflammation / loss of Vascular Structure**
  • *PSEUDOPOLYPS**
  • *Erythema / Friability / Superficial Ulceration**

Pathalogy
Cypt ATROPHY / Neutrophil Infiltration
DIstortion of villous architecture / Paneth Cell metaplasia

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6
Q

Crohn’s Disease Differences

Disease Location

Endoscopic Visualization

Pathalogy

A

Disease Location
ENTIRE GI TRACT, oral cavity -> Rectom
commonl affeccts Terminal Ileum

Endoscopic Visualization

  • *Granulomatous Inflammation = COBBLESTONE**
  • *Skip Lesions** / transmural inflammation

Pathalogy
Crypt abscesses / granulomas
inflammation w/ lymphoid aggregates

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7
Q

Antibody Tests

IBD Serologic Markers​

A

Used to:
DISTINGUISH UC from CD

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8
Q

C-Reactive Protein

IBD Serologic Markers​

A

Non-specific

Can correlate with DISEASE ACTIVITY
&
be used DURING FLARE

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9
Q

Fecal CalProtectin

IBD Serologic Markers​

A

Stool Marker

indentifies LARGE intestinal Inflammation

Correlates with Disease Activity
&
can assist with monitoring Disease PROGRESSION

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10
Q

Naming of UC

A

Proctitis = Rectum
only rectum –> 60-95% of pts

Proctosigmoiditis** = Rectum + Sigmoid Colon

Pancolitis
inflammationt hat extends Past splenic flexure = ALL COLON

Left Sided or Distal Disease
inflammation that extends to splenic Flexure

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11
Q

Which IBD, Clinical Manifestation

AB Pain / Mass

Fatigue / Weight Loss

Fever

Chronic / Nocturnal Diarrhea

A

CROHNS DISEASE

More common in Females, entire GI tract

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12
Q

Which IBD, Clinical Manifestation

Diarrhea +/- Blood

Tenesmus
urge to go when you cant

^Stool Urgency / Frequency

Rectal Bleeding

Toxic Megacolon

A

ULCERATIVE COLITIS

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13
Q

ExtraIntestinal Manifestation = EIM

A

20-40% IBD patients will have inflammation in:
Other Organ Systems

  • *Treating IBD –> treats EIM**
  • may or may NOT correlate with IBD flare*

Rheuma / Derma / Hepata

Ocular / Hemat / Bones

Nephro / Pancrea

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14
Q

Truelove & Witts

Determines Criteria for WHAT & Based on What?

A
  • *UC**
  • *Truelove + Witts**

Mild - Moderate - Severe - Fulminant

Based on:
Stool Frequency / Blood in Stools

Temp / HR / HgB / ESR

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15
Q

CDAI

Determines criteria for WHAT?
&
Severe/Fulminant Criteria

A
  • *CD**
  • *Crohn’s Disease Activity Index**

Severe / Fulminant
CDAI > 450

Persistant Symptoms despite treatment w/ steroids/biologics
OR
High Temp / Vomiting / Obstruction
Peritoneal Signs / Cachexia / Abscess

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16
Q

AminoSalicylates
SulfaSalazine / Balsalazide / Olsalazine
5-ASA = ​Mesalamine

Indicated for what IBD / Severity?

Action / MoA

A

First Line Therapy for:
MILD-MODERATE IBD
to both Induce & Maintain Remission

UC > CD
in terms of effectiveness

Exerts pharmacologic action TOPICALLY in the gut

  • *Anti-Inflammatory**
  • inhibits* proinflammatory prostaglandins / leukotrines / cytokine synthesis
  • *Immunosupressive**
  • BLOCKS* lymphocyte DNA synthesis / T-cell Proliferation
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17
Q

Sulfasalazine
AminoSalicylate

Site of Action / Clinical Pearl

A

Azulfidine @COLON

Male INFERTILITY (reversible)

may turn Urine ORANGE / stain contacts

Needs Folic Acid supplementation

  • *Sulfasalazine = PRODRUG**
  • *Mesalamine (5-ASA) is the ACTIVE drug**
  • *Sulfapyridine causes the SIDE EFFECTS** = HEADACHE
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18
Q

Sulfasalazine
AminoSalicylate

Formulation / Hypersensitivity

A
  • *Sulfasalazine = Prodrug**
    1) Mesalamine = 5-ASA = Active Drug
    2) SULFAPYRIDINE = causes Side effects
  • *DOSE RELATED**, can cause HEADACHE / nausea + fatigue

Hypersensitivity / SULFA ALLERGY
NOT DOSE RELATED
Should be stopped immediately if:
SJS / Fever / Arthralgias / Hepatic or Hematologic Toxicity

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19
Q

Olsalazine
AminoSalicylate

Site of Action / Clinical Pearl

A
  • *Dipentum @ COLON**
  • *2X 5-ASA** joined by AZO bond

Same clinical pearls as Balsalazide

SA: HA / Nausea / Ab pain
WATERY DIARRHEA
15% –> should be switched to –> MESALAMINE agent

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20
Q

Balsalazide
AminoSalicylate

Site of Action / Clinical Pearl

A
  • *Colazal @ COLON**
  • *5-ASA** linked to inert unabsorbed carrier molecule

Same clinical pearls as Olsalazine

SA: HA / Nausea / Ab pain
WATERY DIARRHEA
15% –> should be switched to –> MESALAMINE agent

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21
Q
  • *Mesalamine**
  • *5-ASA (Aminosalycylate)**

ENEMA / RECTUM
site of action

A

Rowasa = Enema
@Descending Colon + Rectum
Give at bedtime + lay on LEFT SIDE for 8 hours

Canasa = Suppository
@ Rectum
need Bowel Movement first

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22
Q

Which Mesalamine Formulation(s) acts on:
TERMINAL ILEUM+Colon

A

“LAD” -> Ileum

Lialda
​1200mg Tab

Asacol HD
800mg Tablet

Delzicol
400mg Cap

ADR of all Mesalamines = Diarrhea @ initiation

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23
Q

Which Mesalamine Formulation(s) acts on:
JEJUNUM + Colon

A

APRISO
375mg Cap

APRISO -> JEJUNUM

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24
Q

Which Mesalamine Formulation(s) acts on:
SMALL BOWEL + Colon

A

PENTASA
250mg / 500mg

  • *PENTA = A LOT
  • -> ENTIRE SMALL + LARGE COLON**
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25
Q

5-ASA = Mesalamine
HyperSensitivity vs Allergy

A

Allergy:
Worsening of Colitis
Diarrhea / Bleeding / Ab Pain / Fever / HA / Rash
D/C and Document as ALLERGY

Hypersensitivity
should be D/C’d IF:
Pancreatitis / Pneumonitis / Nephrotoxicity

26
Q

SULFASALAZINE

MONITORING

A

Sulfapyridine = Haptotoxicity + Blood Issues

CBC

LFTs
@initiation of therapy
q2weeks for 3 months
q1month for 3 months
every 3 months

27
Q

5-Asa = Mesalamine

MONITORING

A

SCr
@6weeks / 6 months / 12 months

Use caution in patients with renal insufficiency

28
Q

CorticoSteroids

IBD INDICATION?

MoA

A

Treatment of: ACTIVE UC or CD

MODERATE-SEVERE disease who require RAPID improvement

SEVERE-FULMINANT disease who face surgery

FAILED 5-ASA therapy

  • HAS NO ROLE AS MAINTANENCE*
  • ineffective at MAINTAINING remission + side effects*

MoA: Potent Anti-Inflammatory Agent

29
Q

Budesonide
Entocort / Uceris

IBD Indication

A

Preferred Steroid if:

  • *MILD-MODERATE** symptoms
  • *LONG-TERM steroids are required**

Due to extensive 1st pass metabolism:

  • **_LOW systemic BIOavailability
  • -> MINIMIZE SYSTEMIC SIDE EFFECTS_***
30
Q

UCERIS
Budesonide

Formulation / Indication / Target Location

A

9mg Oral Tablet + RECTAL FOAM

  • *Active Mild-Moderate UC**
  • UC-eris*

Targets:
COLON

Rectal formulation:
40cm from Anal Verge

31
Q

Entocort EC
Budesonide

Formulation / Indication / Target Location

A

3mg ORAL capsule

Active CD
Maintanence of Remission CD

Targets:
Terminal Ileum + Ileum + Ascending Colon

32
Q

AZA & 6-MP
ImmunoModulators for IBD

Indication / Onset / ADR

A

Not FDA Approved:
Used for STEROID-SPARING Effect as Maintenance Agents
combined w/ BIOLOGICS –> REDUCE IMMUNOGENECITY
since the Biologic can mount an immune response

3-6 months

ADR:

  • AVOID IN YOUNG MALES* due to Hepatosplenic T-cell Lymphoma
  • *Hepatotoxicity** (6-MMP)
  • *Bone Marrow Supression** (6-TGN)
  • *Infxn / Pancreatitis / GI disturbances / MALIGNANCY**
33
Q

Which IBD Drug should we avoid in
YOUNG MALES?

A

AZA** / **6-MP
ImmunoModulator Therapies

BBW –> Hepatosplenic T-Cell Lymphoma
in Young Males

34
Q

Crohn’s Disease
COMPLICATIONS

A
  • Fistulas– 40%
  • Abscesses
  • Fissures (ulcer)
  • Nutritional deficiencies – can’t absorb / weight loss
  • Obstruction
  • Stricture – hard to pass
  • Intestinal resection – 60-80%
35
Q

Which IBD Drug
requires TPMT enzyme activity test?

A

AZA** / **6-MP
Immunomodulator Therapies

TPMT –> 6-MMP = Hepatotoxic Metabolites

Deficient / Homozygous <4 = AVOID AZA

Low / HETERozygote 4-12 = Reduce dose by 50%

36
Q

Methothrexate
What needs to be MONITORED during THERAPY?

A

CBC** + **LFTs
weekly 1x month –> Monthly 3mo –> q 3 month
CBC = Bone Marrow Suppression
LFT = Hepatotoxcity

PULMONARY FIBROSIS
= unique ADR

Also is TERATOGENIC

37
Q

AZA & 6-MP
What needs to be MONITORED during THERAPY?

A

CBC** + **LFTs
weekly 1x month –> Monthly 3mo –> q 3 month
CBC = Bone Marrow Suppresion from 6-TGN
LFT = Hepatotoxcity from 6-MMP

6-TGN** & **6MMP
levels if patient is NOT responding

38
Q

CSA + FK (Tacrolimus)

ImmunoModulators ​for IBD

Indication / Onset / ADR

A

Not FDA Approved for IBD:
used for SEVERE, Treatment-Refrectory Colitis (primarily UC)

5-14 days (slow still, but faster)

IV Continuous Infusion

ADR:
Nephrotoxicity / HT / Paresthesia

39
Q

Metronidizole / Ciprofloxacin

Antibiotics ​for IBD

Indication / Onset / ADR

A

only as ADJUNCTIVE therapy
used only if they have an infxn or @risk

Indications:

  • *CD + Abscess or Fistula**
  • *Intestinal or Perianal Disease** or Pouchitis

concern is C.DIFF

ADR:
Metronidazole = Neuropathy / Metallic Taste / Disulfram Rxn
Cipro = Tendon rupture, esp w/ high dose Steroids

40
Q

Methotrexate

ImmunoModulators ​for IBD

Indication / Onset / ADR

A

Not FDA Approved for IBD:
Used for steroid Sparing effect as a Maintenance agent
Combine with BIOLOGICS to reduce immunogenecity

2-8 weeks (slow)

IM/SC + Folic Acid

ADR:
PULMONARY FIBROSIS
Hepatotoxicity / Bone Marrow Suppression
Infection

41
Q

GOLIMUMAB

Brand / Class / Indications / Administration

A

Simponi = Human

Anti-TNFa

UC ONLY

SC dosing

42
Q

CERTOLIZUMAB

Brand / Class / Indications / Administration

A

Cimzia = Peg-human

Anti-TNFa

  • *CD ONLY**
  • *C**imzia / Certolizumab

SC dosing

43
Q

ADALIMUMAB

Brand / Class / Indications / Administration

A

Humira = Human

Anti-TNFa

CD & UC

SC dosing

44
Q

INFLIXIMAB

Brand / Class / Indications / Administration

A

REMICADE = Chimeric

Anti-TNFa

CD & UC

Weight Based dosing:
IV

45
Q

Anti-TNF-a ADRS
Infliximab / Adalimumab / Certolizumab / Golimumab

A

Can worsen CONGESTIVE HEART FAILURE = CHF
dose related - avoid 5mg/kg> of infliximab w/ HF

Hepatotoxicity - LFTs

Bone Marrow Suppression - CBC

  • *Infections**
  • *TB** / herpes / PCP / HEP B

Injection / Infusion site RXNs

BBW = Lymphomas

46
Q

Anti-TNFa MONITORING
Infliximab / Adalimumab / Certolizumab / Golimumab

A

@Initiation

  • *TB / Hep B**
  • *CBC / LFT**

Q3 months = CBC / LFT

Annually = TB / Hep B

TREAT TB b4 INITIATING THERAPY
2 months prior to starting

47
Q

Anti-TNFa
THERAPEUTIC DRUG MONITORING = TDM
Infliximab / Adalimumab / Certolizumab / Golimumab

A

TDM occurs in LOSS of RESPONSE to therapy
or after a DRUG HOLIDAY

Monitor Trough Levels, immediately prior to next dose

Drug Levels
correlate with longer remission + better endoscopy scores

Anti-Drug Antibodies = ADA
decrease efficacy // increase infusion / admin rxns
can develop with anti tnf after prolonged use

48
Q

Primary Non-Responder
AntiTNFa for IBD

A
  • *First time Trying –> NO RESPONSE**
  • *High TDM Trough level** but no response

Factors:
long disease duration > 2 years
Small bowel extent of disease
smoking / normal CRP levels

60% of patients will respond to another ANTITNFa

49
Q

Immunomodulator + Anti-TNFa

Indication for IBD

A
  • *FIRST LINE THERAPY** for
  • *Moderate - Severe CD**

Consider DUAL therapy based on Patient Factors
for Mild-Moderate CD or UC

50
Q

Immunomodulator + Anti-TNFa
Combo for IBD

Positives / Negatives

A

Positives:
Reduces ANTIBODY formation
Increases / maintains - serum drug concentrations
Decrease serum drug clearance = Better Patient Outcomes

Negative:
INCREASED CHANCE FOR LYMPHOMAS + CANCERS

51
Q

VEDOLIZUMAB

Brand / Class / Indications / Administration

A

Entyvio

Leukocyte Adhesion Inhbitor
aka Anti-integrin Molecules

BOTH CD + UC
First Line (prior to Anti-TNFa)
Preffered in patients with IMMUNE CONDITIONS
due to Gut selectivity –> avoids systemic immunosuppression

IV dosing

52
Q

Which IBD Drug is preferred in patients with:
IMMUNE CONDITIONS?

Organ Transplant / Malignancy

A
  • *VEDOLIZUMAB** = Entyvio
  • *Leukocyte Adhesion Inhibitor** for BOTH CD +UC

Due to:

  • *GUT SELECTIVITY**
  • avoids systemic immunosuppresion*
53
Q

NATALIZUMAB

Brand / Class / Indications / Administration

A

Tysabri

Leukocyte Adhesion Inhibitors

CD - Only
Inadequate / can not tolerate Anti-tnf

IV only

54
Q

VEDOLIZUMAB

MoA / ADRs

A

CD & UC

Binds a4/b7 SELECTIVE for GUT

  • *Anti-Integrin molecule** -
  • > reduces leukocyte infiltration & inhibits inflammation

ADR:

  • does NOT need to monitor TB / HEP B*
  • *HA / Nasopharyngitis**
  • lower risk of MALIGNANCY / INFECTIOn*
55
Q

NATALIZUMAB

MoA / ADR

A
  • *CD only**
  • *Anti-Integrin** –> acts on CNS & Gut-Trophic T-cells

BBW** = **PML
Progressive Multifocal Leukoencephalopathy
due to non-selectivity for GUT
REQUIRES REMS-TOUCH PROGRAM

ADRs:
Infections / Hepatotoxicity / abnormal WBC

56
Q

USTEKINUMAB

Brand / Class / Indications / Administration

A

Stelara

Anti-IL-12 / Anti-IL-23

ONLY CD
Moderate - Severe
for those intolerant of immunomodulators or AntiTNF-a

Weight Based Loading dose = IV
+
Maintance Dose = 90mg SC

57
Q

USTEKINUMAB

ADR / Monitoring

A
  • *DRUG-DRUG INTERCTIONS**
  • *CYP substrates**

TB Test @ Initiation + Yearly

CBC @Baseline + Q3Mo

ADRs:
Reactivation of TB // Infections
Malignancy / HA / Fatigue / Inj Site Rxn

58
Q

TOFACITINIB

Brand / Class / Indications / Administration

A

Xeljanz

JAK Enzyme Inhibitor
prevent gene expression of Cytokines & activity of immune cells

for UC only
Moderate - Severe

  • *ORAL DOSING**
  • no immunogencity = small molecule*
59
Q

TOFACITINIB MONITORING

JAK Inhibitor for UC only

A

LIPIDS** / **HERPES ZOSTER INFXN

CBC

Hep B** + **TB Test

CYP3A4 DRUG INTERACTIONS
avoid inducers

(need Shingrix)

60
Q

TOFACITINIB ADR’s

JAK Inhibitor for UC only

A

Reactivation of:
TB / Hep B / Herpes Zoster
ask about shingrix

Nasopharyngitis / Dyslipidemia

Infection / HT / Malignancy

61
Q

UC Treatment

Induction / Maintenance

A
62
Q

CD Treatment

Induction / Maintenance

A

PDAT4 (34 decks)

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