Block 1: IBD

Question 1

What are the diet options for colonoscopy?

Answer 1

1. Clear liquid diet for the day before
   * Avoid red and purple dyed foods
   * Clear liquids can be take up to 2 hr before procedure
2. Low-residue/low fiber diet avoiding seeds and indgestible substnaces (several days before procedures)

Question 2

Type of colonoscopy preps?

Answer 2

Osmoprep Hypertonic solution to mix with water
Suprep More palatable ELS
Magnesium citrate Lacks electrolytes
Nulytely Tablet formulation
Golytely Gold Standard
Miralax Cheapest option

Question 3

Describe the dosing of colonoscopy prep?

Answer 3

Day before: drink entire solution as directed the day prior to procedure
Split dose: Drink 1/2 the solution the day befor and 1/2 morning of solution (3-8 hrs prior)
* May need to wake up early to finish

Day of procedure: Complete the entire solution the morning of the procedure (3-8 hr)
* For patients with afternoon appointments only
* Good quality prep with good tolerability, better sleep quality, and less impact on activities of daily living

Question 4

What are medications you can use for colon prep?

Answer 4

1. Bisacodyl: Increase ADRs
2. Mag citrate: may decrease total fluid requirement or improve prep quality for nonadherent
3. Senna: Increase ADRs

Question 5

What are the types of IBD?

Answer 5

1. CD: transmural inflammation spanning the GIT (mouth to anus)
2. UC: mucosal inflammation confined to rectum/colon

Question 6

Describe the type of inflammation of CD vs UC?

Answer 6

Question 7

What are the causes of IBD?

Answer 7

1. Infectious facotr (proinflammatory bacteria in the gut)
2. Genetic facotrs (first degree relatives = 20 fold risk increase)
3. Immunologic mechanisms: autoimmune
4. Environmental factors: Stress, diet, smoking, medications

Question 8

What are the disease triggers?

Answer 8

Smoking: Protective for UC but increases severity and frequency of CD
NSAID use: Anti-PG effect -> increase risk for ulcers
Diet: Processed proteins, refined sugars, and unsaturated fats increase risk
Antibiotic use: Hygiene hypothesis

Question 9

UC presentations?

Answer 9

1. Abdominal cramping
2. Frequnet bowel movements, blood in stool
3. Weight loss
4. Fever, tachycardia
5. Blurred vision, eye pain, photophobia
6. Arthritis
7. Raised, red, tender nodules

Question 10

Describe the UC severity score?

Answer 10

Mild: 4 stools/day, ESR 30, elevated CRP and fecal calprotectin

Moderate-severe: 6 stools/day blood and urgency, fever, tachycardia, elevated CRP, ESR >30 mm/hr

Filminant: 10 bowels/day continuous bleeding and urgency, toxicity, abdominal tenderness, transfusion, elevated CRP and FC, colonic dilation

Question 11

List the types of UC?

Answer 11

Distal: inflammation limited to areas distal to the splenic flexure (left-sided dx)
Extensive: inflammation extending proximal to the splenic flexure and majority of the colon (pancolitis)
Proctitis: Inflammation confined to rectal area
Proctosigmoiditis: Inflammation involving the rectum and sigmoid colon

Question 12

How do you diagnose UC?

Answer 12

1. Biopsy
2. Stool examinations
3. Sigmoidoscopy or colonoscopy
4. Barium radiographic contrast studies

Question 13

Clinical presentations of Crohn’s Dx?

Answer 13

1. Malaise and fever
2. Abdominal pain
3. Frequnet bowel movements
4. Hematochezia
5. Fistula
6. Weight loss and malnutrition
7. Arthritis

Question 14

Tx of CD?

Answer 14

Question 15

Tx goals of CD?

Answer 15

1. Suppress the inflmmatory response
2. Induce remission
3. Maintain disease remission

Question 16

Non-pharm of CD?

Answer 16

1. Nutritional support: screened for malnutrition deficiencies
2. Elimination diets not recommended
3. Increased red meat, protein, sulfur, and alcohol can flare dx
4. Lactose intolerance
5. Bowel strictures, avoid citrus fruits and nuts
6. Low FODMAP diet
7. Surgery

Question 17

Drugs that that induce remission of CD?

Answer 17

1. 5-ASA: sulfasalazine, mesalamine, osalazine, balsalazide (Well tolerated)
2. Corticosteroids: Presnisone, prednisolone, budesonide (Highly effective, many ADRs)
3. Monoclonal ABX: (highly effective, cost, and ADRs)
4. Immunomodulators

Question 18

What are the 5-ASA?

Answer 18

1. Sulfasalazine
2. Mesalamine

Question 19

What are is sulfasalazine?

Answer 19

Sulfonamide and mesalamine
Mesalamine can be given alone

CI: sulfa allergy

Question 20

What is mesalamine?

Answer 20

Rapidly absorbed in the small intestine but poorly absorbed in the colon

Indication: Left sided disease for enema, proctitis for suppository, topical is more effective

Safe in sulfa allergy

ADR: N/V/D/HA, arthralgia

Question 21

Compare the site of action with the CD products?

Answer 21

Question 22

Looking at the colon how products work best?

Answer 22

Question 23

What are the corticosteroids used for CD?

MOA, ADR, Forms

Answer 23

1. Budesonide
2. Prednisone
3. Prednisolone

MOA: Supress inflammation, modulate immune system, inhibits cytokine production
Form: Parenteral, PO, Rectal
ADR: Hyperglycemia, DLD, osteoporosis, infection, increased appetite, insomnia

Question 24

Types of immunomodulators?

Answer 24

1. Azathioprine
2. Mercaptopurine
3. Methotrexate
4. Cyclosporine

Question 25

Indications of immunomodulators? | ADR, Dosing

Answer 25

**Azathioprine and mercaptopurine:** Long term tx of UC and CD * Patient fails tx with 5-ASA **Cyclosporine:** acute, severe UC patients failing CS, not for CD * Nephrotoxic and neurotoxic * Continuous IV infusion daily **Methotrexate:** maintenacne of CD, decreases need for steroids

Question 26

What are the monoclonal antibodies for CD? | Indications, ADRs

Answer 26

**Infliximab, adalimumab,** certolizumab, golimumab **Indication:** Tx and mx of IBD **ADR:** Infusion-related rx (inflixximab), infection, HF, hepatoxicity, Hep B virus reactivation, malignancy, abtibiodies development

Question 27

What is the difference between biosimilars and generic?

Answer 27

Generic: exact copy of brand name drug Biologics: natural source and can't be exactly copied * No clinically meaningful differences in terms of safety, purity, and potency * Approved by abbreviated process

Question 28

What are the meds used to maintain remission?

Answer 28

1. 5-ASA 2. Budesonide 3. Methotrexate 4. Thiopurines (Azathioprine, mercaptopurine) - Lots of ADRs, toxic 5. Monoclonal antibodies (TNFa inhibitors) 6. Cyclosporine (salvage therapy)

Question 29

Mild-moderate UC induction tx?

Answer 29

**Outpatient:** PO/topical ASA or PO/rectal budesonide **Mesalamine preferred as first line agent over sulfasalazine due to tolerability** **Extensive disease:** Mesalamine 2-3 g/day PO **Distal:** Mesalamine enema or suppository **Extensive left-sided dx:** Enema/suppository with PO mesalamine has additive effects CR budesonide MMX for patients unresponsive to mesalamine

Question 30

Moderate-Severe UC induction tx?

Answer 30

**PO mesalamine or budesonide MMX** **TNF-a inhibitorsor vedolizumab** are preferred agents if unresponsive to 5-ASA therapy or corticosteroids **Treatment naive:** infliximab or vedolizumab in combo with immunomodulators (azathioprine)

Question 31

Tx for UC severe or fulminant dx?

Answer 31

1. Requires hospitalization 2. NPO to promote bowel rest 3. Parenteral 4. Test for C dif 5. Recieve VTE prophylaxis (Lovenox, Heparin, fondaparinux) 6. Methylprednisolone IV at dose of 40-60 mg daily is first line agent x 3-5 days before surgery

Question 32

UC maintenace if remission?

Answer 32

**Mild expensive or left-sided:** Mesalamine 2g/d **Proctitis:** Mesalamine suppository 1g/d **Moderate to severe:** 5-ASA may work with agent like azathioprine * Failure of azathioprine or steroid dependent, biologics are good options **Corticosteroids are a no-go for maintenance**

Question 33

Mild to moderate CD?

Answer 33

1. Mesalamine as initial therapy (Pentasa to reach small intestine 2. Controlled-release budesonide first line option for ileal disease

Question 34

Moderate to severe CD?

Answer 34

1. Require rapid suppresion of inflammation to prevent complications 2. Common combo of TNF-a inhibitors with azathiopurine 3. PO CS first-line if unresponsive to 5-ASA (prednisone 40-60 mg/d) * IV if hospitalized and unable to tolerate PO

Question 35

Tx of severe/fulminant CD?

Answer 35

1. Likely requires surgery 2. May consider TNF-aI

Question 36

Tx for CD remission?

Answer 36

1. More difficult to achieve and maintain than UC 2. TNF-a inhibitors are good maintenance * Add thiopurine to enhance efficacy and extend the suration of THNF-a inhibitor efficacy