66. Inflammatory Bowel Disease (IBD) Flashcards
A physician has ordered infliximab. The pharmacist calls the prescriber to ask if she wishes to pre-medicate with acetaminophen, antihistamine and steroids. Which of the following statements is correct?
A. This regimen may be used for infusion related reactions from infliximab therapy.
B. This regimen may be used for infusion related reactions from fluconazole therapy.
C. This regimen may be used for infusion related reactions from tacrolimus therapy.
D. This regimen is missing ondansetron for prophylaxis against nausea and vomiting.
E. Only acetaminophen and an antihistamine should be used for infusion related reactions from infliximab. Steroids should be avoided due to side effect profile.
A. Patients on infliximab may be pre-treated with acetaminophen, antihistamine and/or steroids to prevent infusion reactions, such as hypotension, fever, chills, and pruritus.
Chief Complaint: “I am going to the bathroom 10 times a day”
History of Present Illness: MJ is a 32 y/o female who presents to the ER today. She describes a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is now blood in the stool sometimes. She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn’t weigh herself regularly, so she doesn’t know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).
Allergies: sulfa
Past Medical History: none
Medications: Seasonique
Physical Exam / Vitals:
Height: 5’10” Weight: 122 pounds
BP: 128/75 mmHg HR: 102 BPM RR: 14 BPM Temp: 99.2°F Pain: 2/10
Labs:
Na (mEq/L) = 142 (135 – 145)
WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)
K (mEq/L) = 4.8 (3.5 – 5)
Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)
Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)
ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)
Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)
ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 4.2 (2.3 – 4.7)
Tests:
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout GI tract.
Plan:
Admit for consultation with GI service.
Question:
MJ needs to be treated for her acute IBD exacerbation. Which of the following is an appropriate recommendation?
A. Vedolizumab IV
B. Certolizumab SC
C. Loperamide PO
D. Prednisone PO
E. Methotrexate PO
D. Exacerbations of UC and Crohn’s are treated with short courses of IV or oral steroids.
Which of the following can occur with the use of infliximab? (Select ALL that apply.)
A. Infusion-related reactions
B. Renal insufficiency
C. Antibody induction
D. Hepatotoxicity
E. Reactivation of latent TB
A, C, D, E. Use of infliximab can be associated with infusion-related reactions (hypotension, fever, chills, pruritus), antibody induction, hepatotoxicity, and reactivation of latent TB.
Chief Complaint: “I am going to the bathroom 10 times a day”
History of Present Illness: MJ is a 32 y/o female who presents to the ER today. She describes a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is now blood in the stool sometimes. She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn’t weigh herself regularly, so she doesn’t know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).
Allergies: sulfa
Past Medical History: none
Medications: Seasonique
Physical Exam / Vitals:
Height: 5’10” Weight: 122 pounds
BP: 128/75 mmHg HR: 102 BPM RR: 14 BPM Temp: 99.2°F Pain: 5/10
Labs:
Na (mEq/L) = 142 (135 – 145)
WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)
K (mEq/L) = 4.8 (3.5 – 5)
Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)
Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)
ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)
Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)
ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 4.2 (2.3 – 4.7)
Tests:
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout GI tract.
Plan:
Admit for consultation with GI service.
Question:
The Gastroenterologist diagnoses MJ with Crohn’s disease. After 72 hours of therapy in the hospital she is feeling better, having fewer loose stools, and less pain. Which of the following is the best medication to discharge MJ on?
A. Entocort EC capsules PO
B. Uceris tablets PO
C. Uceris rectal foam
D. Azulfadine PO
E. Canasa suppositories
A. MJ has Crohn’s disease of the ascending/transverse colon and ileum. Entocort EC is specifically indicated for Crohn’s in that location. She does not have distal disease, so topical products will not be effective. Uceris tablets are indicated only for UC. The patient has a sulfa allergy.
Which of the following drugs can cause the skin or urine to become orange-yellowish in color?
A. Methotrexate
B. Mesalamine
C. Ciprofloxacin
D. Infliximab
E. Sulfasalazine
E. Sulfasalazine can cause the skin or urine to become orange-yellowish in color. It is considered harmless but can stain clothing.
A patient with ulcerative colitis is being initated on sulfasalazine therapy. Which of the following situations would represent a contraindication to the use of sulfasalazine?
A. A history of coronary artery disease
B. High triglycerides
C. A history of gout
D. A history of severe sunburns
E. A sulfa or salicylate allergy
E. Sulfasalazine is contraindicated in patients with a sulfa or salicylate allergy. Remember it is an aminosalicylate. Mesalamine can be used in patients with a sulfa allergy.
In addition to loperamide, which other agent is sometimes used to help control diarrhea in patients with Crohn’s?
A. Psyllium
B. Sennosides
C. Docusate
D. Bisacodyl
E. Mineral oil
A. Psyllium and other bulk-forming agents may be useful to treat diarrhea in patients with Crohn’s disease. Psyllium is useful for both diarrhea (by firming up stool) and for constipation (by mixing in and making the stool more spongy).
Which of the following is a first-line treatment option for a patient newly diagnosed with distal mild-to-moderate ulcerative colitis?
A. Sulfasalazine oral
B. Azathioprine oral
C. Mesalamine suppository
D. Infliximab injection
E. Methotrexate oral
C. Mesalamine enemas or mesalamine rectal suppositories are first-line for mild-to-moderate distal ulcerative colitis. When treating distal disease (rectum and colon) it is preferable to insert the medication into the rectum to apply the treatment where the problem is, rather than using systemic therapy, which is not as targeted and will cause more side effects.
Which of the following are true statements regarding mesalamine enemas? (Select ALL that apply.)
A. Administer once daily at bedtime.
B. Patients should ideally retain overnight (8 hours).
C. Topical mesalamine is preferred for proximal disease.
D. The medication is generally prescribed for 1 week at a time because it is poorly tolerated.
E. Store at room temperature.
A, B, E. Mesalamine enemas should be administered once daily at bedtime and ideally, retained for 8 hours. They can be stored at room temperature. Topical mesalamine is the route of choice for distal disease (primarily in ulcerative colitis).
A patient has received oral prednisone 40 mg x 7 days for an acute flare of ulcerative colitis. Which of the following short-term adverse effects may occur?
A. Cataracts and poor wound healing
B. Osteoporosis and immunosuppression
C. Fat deposits in the face and adrenal suppression
D. Cushing syndrome and growth retardation
E. Insomnia and mood changes
E. A patient started on 40 mg daily of prednisone may experience elevated blood pressure, changes in mood, and elevated glood glucose, among other adverse effects. The remaining choices are long-term adverse effects of corticosteroids.
Chief Complaint: “I am going to the bathroom 10 times a day”
History of Present Illness: MJ is a 32 y/o female who presents to the ER today. She describes a 2-week history of increasing abdominal pain and frequency of bowel movements. It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day. There is now blood in the stool sometimes. She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse. She has lost weight, but doesn’t weigh herself regularly, so she doesn’t know how much. MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).
Allergies: sulfa
Past Medical History: none
Medications: Seasonique
Physical Exam / Vitals:
Height: 5’10” Weight: 122 pounds
BP: 128/75 mmHg HR: 102 BPM RR: 14 BPM Temp: 99.2°F Pain: 2/10
Labs:
Na (mEq/L) = 142 (135 – 145)
WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)
K (mEq/L) = 4.8 (3.5 – 5)
Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)
Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)
ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)
Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)
ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 4.2 (2.3 – 4.7)
Tests:
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum. Rectum appears unaffected. Numerous strictures and bleeding are noted throughout GI tract.
Plan:
Admit for consultation with GI service.
Question:
Based on the case above, what is MJ’s most likely diagnosis?
A. Irritable bowel syndrome
B. Ulcerative colitis
C. Crohn’s disease
D. Infectious diarrhea
E. C. difficile associated diarrhea
C. MJ most likely has Crohn’s disease based on the presence of numerous strictures, discontinuous pattern of inflammation, and location throughout the GI tract. Her colon and ileum are affected and rectum is spared. UC generally affects the rectum.
Which statements are true regarding Asacol HD? (Select ALL that apply.)
A. It contains salicylates.
B. It is delayed-release.
C. It should be avoided in a patient who has difficulty breathing with aspirin.
D. It can be crushed and administered via a nasogastric tube
E. The patient may see Asacol HD in the stool.
A, B, C, E. Asacol HD is a delayed-release oral mesalamine tablet administered TID. It contains salicylates and should be avoided in patients with a salicylate allergy. The patient may see a ghost tablet in the feces, they should not be alarmed.
Which of the following are monoclonal antibodies approved for the treatment of IBD?
A. Remicade, Rituxan, Cimzia
B. Humira, Remicade, Tysabri
C. Rituxan, Entyvio, Simponi
D. Humira, Enbrel, Cimzia
E. Remicade, Simponi, Enbrel
B. Rituxan and Enbrel are not approved for IBD. The monoclonal antibodies that are approved for IBD have specific FDA-approved indications for UC, CD, or both.
Which of the following is true of vedolizumab?
A. Vedolizumab is approved only for Crohn’s disease.
B. Vedolizumab has a boxed warning for PML.
C. The brand name of vedolizumab is Entyvio
D. Vedolizumab must be used in conjunction with another immunosuppressant.
E. Vedolizumab is an integrin receptor agonist.
C. Vedolizumab was approved in 2014 for UC and Crohn’s disease. It is a monoclonal antibody - specifically an integrin receptor antagonist. Patients on vedolizumab should be monitored for PML, though it has not been observed with this drug to date.
Keith has ulcerative colitis that is extensive. He has been started on sulfasalazine therapy. Choose the correct counseling statement for sulfasalazine:
A. The brand name is Asacol-HD.
B. Common side effects are headache, nausea and decreased appetite.
C. Sulfasalazine is contraindicated in a penicillin allergy.
D. Take this medication before meals on an empty stomach.
E. Sulfasalazine is also used to treat osteoarthritis.
B. Counseling points for sulfasalazine delayed-release tablets (Azulfidine EN-tabs) include: can rarely cause serious blood disorders, including agranulocytosis. Patients should be instructed to report at once if they have symptoms of an infection (fever, sore throat). It is contraindicated in a sulfa allergy. Drink plenty of fluids during treatment with this medication to help prevent kidney stones. Take after a meal when there is food in the stomach.
