74. IBD Flashcards
Major types of IBD are ___
ulcerative colitis and crohn’s disease
IBD is a group of inflammatory conditions of the _____
colon and small intestine
Classic symptom of IBD is ___
bloody diarrhea
inflammatory bowel disease can be mistaken for irritable bowel syndrome as they have similar symptoms such as ____ but unlike IBD, IBS does not cause ___
abd pain, bloating, gas, constipation or diarrhea
IBD does not cause inflammation
Ulcerative colitis is characterized by mucosal inflammation confined to ____
rectum and colon with superficial ulcerations
When UC is limited to descending colon and rectum, it is called ___ and can be treated with ____
distal disease
can be treated with topical rectal treatment
Inflammation limited to rectum is called ___
proctitis
Crohn’s disease is characterized by ___
deep, transmural (through the bowel wall) inflammation that can affect any part of the GI tract
Symptoms of Crohn’s disease include ____
chronic diarrhea (often nocturnal)
Others: abdominal pain, weight loss
Perianal symptoms (e.g. bleeding, fissures (tears)) can be present before bowel symptoms
Compare Crohn’s disease and ulcerative colitis regarding fistulas/strictures
Common in CD
Uncommon in UC
Compare Crohn’s disease and ulcerative colitis regarding location
CD = entire GI tract (esp ileum and colon)
UC = colon (esp rectum)
Compare Crohn’s disease and ulcerative colitis regarding depth
CD = transmural
UC = superficial
Compare Crohn’s disease and ulcerative colitis regarding smokine
CD = risk factor
UC = protective
What can be used to diagnose IBD?
Labs and stool testing can help but usually colonoscopy with tissue biopsy is needed to dx
Lifestyle measures for IBD
eat smaller, more frequent meals that are low in fat and airy
Fiber
Drink plenty of water
Avoid alcohol, caffeine, carbonated beverages
Antidiarrheals or antispasmodic drugs (e.g. dicyclomine (Bentyl) may help diarrhea
Vit supps (e.g. B12, folate, vit D, calcium, iron, zinc) can help prevent deficiencies related to malabsorption
Probiotics Lactobacillus or Bifidobacterium infantis can reduce abd pain, bloating, urgency, constipation or diarrhea in some pts
Natural products that may help with IBD?
Peppermint, chamomile, horehound, wheatgrass
T/F: short courses of oral or IV steroids are commonly used to treat acute exacerbations in both UC and CD.
True
When using systemic steroids for UC or CD, it is generally not recommended for maintenance of remission and will usually be tapered over ____ once remission is achieved
8-12 weeks
Compare CD and UC maintenance of remission for mild disease
CD mild disease of ileum and/or right colon: oral budesonide for ≤3 months; d/c after this course or change to thiopurine or methotrexate
UC mild disease: mesalamine (5-ASA_ rectal and/or oral preferred
Compare CD and UC maintenance of remission for moderate-severe disease
CD: anti-TNF agents (Adalimumab (Humira), Infliximab (Remicade), Certolizumab (Cimzia)), thiopurine (azathioprine, mecaptopurine), methotrexate, IL receptor antagonist (Ustekinumab (Stelara))
UC: anti-TNF agents (Adalimumab (Humira), Infliximab (Remicade), Certolizumab (Cimzia)), thiopurine (azathioprine, mecaptopurine), cyclosporine, IL receptor antagonist (Ustekinumab (Stelara))
Only difference is methotrexate for CD, cyclopsorine for UC. all other options can be used in either
Compare CD and UC maintenance of remission for refractory to first line treatments and/or steroid dependent
CD: integrin receptor antagonists (vedolizumab (Entyvio), natalizumab (Tysabri))
UC: integrin receptor antagonists (vedolizumab (Entyvio)), Janus kinase inhibitor (Tofacitinib (Xeljanz))
What formulation of budesonide is CD only vs UC only?
Budesonide (Entocort EC) 3mg ER cap = CD only
Budesonide (Uceris) 9mg ER tab = UC only
Examples of oral steroids used in IBD
prednisone
Budesonide (Entocort EC, Uceris)
Examples of rectal steroids used in IBD
Hyrdrocortisone (Cortenema, Cortifoam)
Budesonide rectal foam (Uceris)
Rectal steroids are indicated for ___ only
UC
If using steroids for IBD, pts can use alternate day therapy (ADT) to decrease ____ and other adverse effects
Decrease adrenal suppression
Budesonide is a major substrate of CYP___
3A4
Avoid inhibitors including grapefruit juice and products
____ is the primary aminosalicylate used in the US for UC (well tolerated and available both PO and rectal)
Mesalamine (5-ASA)
Mesalamine ER suppository (Canasa) administration notes
1g rectally QHS, retain for at least 1-3 hrs
Mesalamine ER enema (Rowasa) administration notes
4g rectally QHS, retain in the rectum overnight for approx 8 hrs
Mesalamine ER formulations
ER capsules (Pentasa, Aprisa, Delzicol)
ER tabs (Asacol HD, Lialda)
Enema (Rowasa)
Suppository (Canasa)
What formulation of mesalamine is more effective for distal disease/proctitis in US?
Rectal mesalamine > oral mesalamine or rectal steroids
Which formulations of mesalamine ER can leave ghost tab in the stool?
Asacol and Delzicol
Contraindications to mesalamine
Hypersensitivity to salicylates or aminosalicylates
Warnings for mesalamine
Hypersensitivity reactions more likely with sulfasalazine than mesalamine
Others: acute intolerance syndrome, caution in pts with renal/hep impairment, delayed gastric retention can delay release of oral products in the colon, increase risk of blood dyscrasis in pts > 65 yo, photosensitivity
Contraindications for sulfasalazine
Salicylate allergy, sulfa allergy, intestinal or urinary obstruction, porphyria
Why is sulfasalazine used less commonly than mesalamine?
d/t many side effects a/w sulfapyridine component
Thiopurines (Azathioprine, mercaptopurine) place in therapy for IBD
not FDA indicated but recommended as an option in guidelines for induction and maintenance of remission often in combo with other drugs
Warnings for azathioprine
Genetic deficiency of TPMT are at increased risk of myelosuppression
Consider TPMT genetic testing prior to starting
Azathioprine is metabolized to ___
mercaptopurine
Do not use the thiopurines in combination
Monitoring for azathioprine
CBC (weekly for first month)
Others: LFTs, renal function, s/sx malignancy
Methotrexate dosing and place in therapy for IBD
Not FDA indicated for IBD but recommended as otpion in guideline for induction and maintenance of remission in mod-severe CD pts who cannot tolerate azathioprine
Dosed once weekly IM or SC injection
Cyclosporine place in therapy for IBD
Severe UC
Can be given PO or via IV continuous infusion
Anti-TNF agents used in both CD and UC
Adalimumab (Humira)
Infliximab (Remicade)
Certolizumab (Cimzia)
Integrin receptor antagonists (Natalizumab (Tysabri), Vedolizumab (Entyvio)) place in therapy for IBD
Induction and maintenance of remission in pts with IBD who have responded inadequately or cannot tolerate conventional therapies, or in pts who are steroid-dependent
Natalizumab (Tysabri) dosing frequency
300mg IV over 1hr every 4 weeks
Natalizumab (Tysabri) should be d/c if no response by ___
12 weeks
Natalizumab (Tysabri) approved for ___
Crohn’s disease and multiple sclerosis
Vedolizumab (Entyvio) should be d/c if no response by ___
Week 14
Natalizumab (Tysabri) approved for ___
Crohn’s disease and UC
Boxed warning for natalizumab (Tysabri)
Progressive multifocal leukoencephalopathy (PML) - opportunistic viral infection of brain that leads to death or severe disability)_
Only available through REMS TOUCH prescribing program
