3. IBD Flashcards
What are some key features of IBD?
- abnormal activation of the immune system
- chronic inflammation
- lifelong disease
What are the racial risk factors for IBD?
white > African American > Hispanic and Asian
What are some theoretical causes of IBD?
- infectious
- genetic
- immunologic
- environmental
- psychological
First degree relatives of people with IBD have ___x risk themselves.
20
Smoking is _______ for UC and _________ for CD
protective
increases
UC is confined to the ______ and _______.
rectum
colon
UC presents with continuous, _______, _________ inflammation.
diffuse
surface
CD can present in _________ of GI.
any part
What is the most common site of CD?
terminal ileum
What characterizes mild UC?
> 4 stools per day
+/- blood
No systemic disturbances
Normal ESR
What is ESR?
Erythrocyte Sedimentation Rate
What characterizes moderate UC?
- > 4 stools/day
- minimal systemic disturbance
What characterizes severe UC?
- > 6 stools/day
- blood +
- evident systemic disturbance
- ESR > 30
What is UC: distal disease?
- aka left-sided disease
- limited to areas below the splenic fixture
What is UC: extensive disease?
pancolitis - involves the entire colon
What is UC: proctitis?
- most common form
- inflammation confined to the rectal area
What is UC: prostosigmoiditis?
inflammation of the rectum and sigmoid colon
What characterizes mild/moderate CD?
- NO dehydration, systemic toxicity, weight loss, tenderness, mass/obstruction
- diarrhea, abdominal pain, possible lesion
What characterizes moderate/severe CD?
- Failure to respond to treatment
- fever, weight loss, abd. pain/tenderness, vomiting, anemia
What characterizes severe/fulminant CD?
- Failure of outpatient corticosteroid treatment
- High fever, cachexia, rebound tenderness, abscess, obstruction, strictures
What is CD: enteritis?
- located in small intestine
- left untreated will probably result in SI obstruction
What is CD: terminal illeitis?
- located at the very end of the SI
- fistulas and abscesses can occur
What is CD: colitis?
- located in the colon
- diarrhea, pain, fistula, abscess
- most common site for a skin/joint response; granulomatous colitis
What is CD: entero-colitis/ ileo-colitis?
- involves both the small and large intestines
- diarrhea, weight loss, cramping
- MOST common form
What tissue does UC affect?
mucosa and submucosa
What are the primary lesions of UC?
crypt abscesses
Crypt abscesses form ________.
pseudopolyps
What are the local complications of UC suffered by most patients?
- hemorrhoids, anal fissures, perirectal abscess
- toxic megacolon
In CD, _____ ____ injury is extensive.
bowel wall
In CD, the ________ ______ is often narrowed.
intestinal lumen
What is the typical appearance of CD?
“cobblestone” - deep, elongated ulcers
What are the local complications of CD?
stricture/obstruction
fistulae
What are the complications and treatments for a stricture?
- can narrow enough to cause obstruction
- may need surgery
Where do fistulae occur and what are the treatments for fistulae?
- occur in the worst areas of inflammation
- frequently need surgery
What are the 3 main methods for IBD diagnosis?
Imaging
Biopsy
Labs
What image testing is commonly done in IBD?
colonoscopy
barium radiographic contrast
What lab results can help diagnose IBD?
- leukocytosis
- anemia
- increased ESR, CRP
- stool studies
What are some extra-intestinal IBD complications?
- hepatobiliary
- joint
- ocular
- dermatologic
What are some hepatobiliary complications of IBD?
- pericholangitis, fatty liver, chronic hepatitis, cirrhosis
- sclerosing cholangitis, gallstones, cholangiocarcinoma
What are some joint complications of IBD?
- asymmetrical arthritis: knees, hips, ankles, wrists, elbows
- sacroiliitis, ankylosing spondylitis
What are some dermatologic complications of CD?
- apthous stomatitis
- erythema nodosum
What are some dermatologic complications of UC?
pyoderma gangrenosum
What are the 3 main treatment goals of IBD?
- induce remission
- maintain remission
- maintain quality of life
What is the active component of Aminosalicylates?
5-aminosalicylate (5-ASA)
What is the purpose of using aminosalicylates?
induce and maintain remission
Most aminosalicylates are released in the _______. These do not work well in ____ especially when it is in the _____ ______.
colon
CD
small intestine
What is the MOA of aminosalicylates?
anti-inflammatory effects due to inhibition of leukotriene production and anti-prostiglandin and anti-oxidant effects
Aminosalicylates may be protective against ______.
cancer
Sulfasalazine belongs in which category?
aminosalicylates
Sulfasalazine is the combination of what 2 drugs?
sulfapyridine + mesalamine
Sulfasalazine is cleaved by what?
gut bacteria
In Sulfasalazine, which is the active component?
mesalamine
In whom should you avoid using Sulfasalazine?
those with sulfa allergies
males trying to conceive
What are some serious effects of Sulfasalazine?
- bone marrow suppression
- hemolytic anemia
- hepatotoxicity
Mesalamine is formulated by itself. (T/F)
True. Mesalamine is formulated alone and with sulfapyridine (sulfasalazine)
What is first line for mild/moderate UC and CD?
mesalamine
What formulations is mesalamine available in?
oral (and prodrugs) and topical
Which formulation of mesalamine is superior in inducing remission with distal disease?
the combination of the oral and topical
Where is the site of action for mesalamine controlled release?
continuous delivery throughout the GI tract
Where is the site of action for mesalamine delayed release?
delivery to the distal ileum and colon
Where is the site of action for Sulfasalazine and the mesalamine prodrugs?
colon
What is the purpose of administering corticosteroids to IBD patients?
induction of remission only (not for maintenance therapy)
What formulations of corticosteroids are available for IBD?
topical and systemic
Patients with _______ disease may become steroid _________.
severe
dependent
What is the conventional dose for oral Prednisone in IBD?
0.5 - 1 mg/kg/day
What is the maximum dose for oral Prednisone in IBD?
40 - 60 mg/day
In what patient group is parenteral corticosteroid therapy indicated?
- severe colitis, refractory to oral corticosteroids who require hospitalization
- patients with systemic toxicity
Using the ______ formulation of corticosteroids has the _______ response time.
rectal
faster
In rectal corticosteroid therapy, the foam formulation reaches __ - __ cm from the ________.
15 - 20 cm
rectum
In rectal corticosteroid therapy, the enema formulation reaches to the _______ ________.
splenic fixture
What is the side of action for Budesonide?
terminal ileum
What is the dose of Budesonide?
9 mg/day
What formulation of Budesonide is appropriate for CD?
Entocort EC
What formulation of Budesonide is appropriate for UC?
Uceris
What is the mainstay of antibiotic therapy for IBD?
metronidazole
Why are antibiotics used in IBD?
They suppress cell-mediated immunity.
When are antibiotics indicated in IBD?
CD: perianal disease, fistulas
UC: pouchitis
What is the dose for metronidazole in IBD?
10-20 mg/kg/day BID to QID
What is the main ADR for metronidazole and is it permanent?
peripheral neuropathy 85%
no
Why would Ciprofloxacin be used in IBD?
in patients who cannot tolerate metronidazole
Why would Rifaxamin be used in IBD?
it is not systemically absorbed, so it would remain in the GI tract and is appropriate for infectious etiology
What is the onset of action for immunomodulators?
3 - 6 months
What are the thiopurine immunomodulators?
azathioprine and 6-MP
Cyclosporin and Tacrolimus are dosed to _______.
target
Before starting a patient on a thiopurine medication, it is important to test what?
thipourine metabolite activity
If a patient is an intermediate metabolizer of thiopurines, what needs to be done?
50% dose reduction
If a patient is a poor metabolizer of thiopurines, what needs to be done?
this patient is not a candidate for this therapy
What is the purpose of administering allopurinol with thiopurines?
Allopurinol shunts the metabolism to the preferential 6-TG metabolite.
What is the most common target for biologic agents?
TNF - α
TNF - α plays and active role in events leading to ______ __________.
mucosal inflammation
In what ways does TNF - α contribute to the IBD disease process?
- Direct tissue injury
- Activation/ recruitment of inflammatory cells
- Enhanced cytokine secretion
- Direct apoptosis of mucosal epithelial cells
What is the drug name ending for biologic agents?
-umab
Biologic agents are used only for maintenance therapy. (T/F)
False: induction and maintenance
Which biologic agents are appropriate for CD and UC?
- Infliximab
- Adalimumab
- Vedolizumab
Which biologic agents are only used for CD?
- Certolizumab
- Natalizumab
Which biologic agents are only used for UC?
- Golimumab
Biologic agents increase the risk of what?
- infection
- lymphoma
- TB
Infliximab targets ______.
TNF-α
Infliximab is indicated for what degree of disease?
moderate to severe
Infliximab is available in what formulation?
IV only
What is the target level of Infliximab
3 - 7 mcg/mL
What are some contraindications for infliximab?
- active infection
- untreated latent TB
- moderate - severe HF
- current or recent malignancies
Adalimumab targets ______.
TNF-α
Adalimumab is indicated for what degree of disease?
moderate to severe that is unresponsive to other therapies or to Infliximab
Adalimumab is available in what formulation?
SQ
Certolizumab is linked to ___ and targets _____.
PEG
TNF-α
Certolizumab is indicated for what?
CD
Certolizumab is available in what formulation?
SQ
Golimumab targets ___.
TNF-α
Golimumab is indicated for what?
moderate to severe UC
Golimumab is available in what formulation?
SQ
Natalizumab targets ____.
α4-integrin
Natalizumab is indicated for what?
moderate to severe CD with inadequate response to conventional therapies and anti-TNFs
Which biologic agents are in the REMS program?
Natalizumab
Natalizumab is available in what formulation?
IV
Vedolizumab targets ____.
α4β7-integrin
Vedolizumab is available in what formulation?
IV
Nicotine replacement is appropriate for UC and CD. (T/F)
False: UC only
What are antispasmodics/antidiarrheals used for in IBD?
adjunctive therapy
What is cholestyramine used for in IBD?
- adjunctive therapy
- bile-salt induced diarrhea after ileal resection
What is the only curative measure for UC?
surgery to remove diseased colon
