74. IBD Flashcards by Yerin M

Major types of IBD are ___

ulcerative colitis and crohn’s disease

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IBD is a group of inflammatory conditions of the _____

colon and small intestine

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Classic symptom of IBD is ___

bloody diarrhea

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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

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Ulcerative colitis is characterized by mucosal inflammation confined to ____

rectum and colon with superficial ulcerations

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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

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Inflammation limited to rectum is called ___

proctitis

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Crohn’s disease is characterized by ___

deep, transmural (through the bowel wall) inflammation that can affect any part of the GI tract

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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

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Compare Crohn’s disease and ulcerative colitis regarding fistulas/strictures

Common in CD
Uncommon in UC

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Compare Crohn’s disease and ulcerative colitis regarding location

CD = entire GI tract (esp ileum and colon)
UC = colon (esp rectum)

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Compare Crohn’s disease and ulcerative colitis regarding depth

CD = transmural
UC = superficial

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Compare Crohn’s disease and ulcerative colitis regarding smokine

CD = risk factor
UC = protective

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What can be used to diagnose IBD?

Labs and stool testing can help but usually colonoscopy with tissue biopsy is needed to dx

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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

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Natural products that may help with IBD?

Peppermint, chamomile, horehound, wheatgrass

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T/F: short courses of oral or IV steroids are commonly used to treat acute exacerbations in both UC and CD.

True

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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

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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

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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

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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

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