Block 1: IBD Flashcards
What are the diet options for colonoscopy?
- Clear liquid diet for the day before
* Avoid red and purple dyed foods
* Clear liquids can be take up to 2 hr before procedure - Low-residue/low fiber diet avoiding seeds and indgestible substnaces (several days before procedures)
Type of colonoscopy preps?
Osmoprep Hypertonic solution to mix with water
Suprep More palatable ELS
Magnesium citrate Lacks electrolytes
Nulytely Tablet formulation
Golytely Gold Standard
Miralax Cheapest option
Describe the dosing of colonoscopy prep?
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
What are medications you can use for colon prep?
- Bisacodyl: Increase ADRs
- Mag citrate: may decrease total fluid requirement or improve prep quality for nonadherent
- Senna: Increase ADRs
What are the types of IBD?
- CD: transmural inflammation spanning the GIT (mouth to anus)
- UC: mucosal inflammation confined to rectum/colon
Describe the type of inflammation of CD vs UC?
What are the causes of IBD?
- Infectious facotr (proinflammatory bacteria in the gut)
- Genetic facotrs (first degree relatives = 20 fold risk increase)
- Immunologic mechanisms: autoimmune
- Environmental factors: Stress, diet, smoking, medications
What are the disease triggers?
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
UC presentations?
- Abdominal cramping
- Frequnet bowel movements, blood in stool
- Weight loss
- Fever, tachycardia
- Blurred vision, eye pain, photophobia
- Arthritis
- Raised, red, tender nodules
Describe the UC severity score?
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
List the types of UC?
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
How do you diagnose UC?
- Biopsy
- Stool examinations
- Sigmoidoscopy or colonoscopy
- Barium radiographic contrast studies
Clinical presentations of Crohn’s Dx?
- Malaise and fever
- Abdominal pain
- Frequnet bowel movements
- Hematochezia
- Fistula
- Weight loss and malnutrition
- Arthritis
Tx of CD?
Tx goals of CD?
- Suppress the inflmmatory response
- Induce remission
- Maintain disease remission
Non-pharm of CD?
- Nutritional support: screened for malnutrition deficiencies
- Elimination diets not recommended
- Increased red meat, protein, sulfur, and alcohol can flare dx
- Lactose intolerance
- Bowel strictures, avoid citrus fruits and nuts
- Low FODMAP diet
- Surgery
Drugs that that induce remission of CD?
- 5-ASA: sulfasalazine, mesalamine, osalazine, balsalazide (Well tolerated)
- Corticosteroids: Presnisone, prednisolone, budesonide (Highly effective, many ADRs)
- Monoclonal ABX: (highly effective, cost, and ADRs)
- Immunomodulators
What are the 5-ASA?
- Sulfasalazine
- Mesalamine
What are is sulfasalazine?
Sulfonamide and mesalamine
Mesalamine can be given alone
CI: sulfa allergy
What is mesalamine?
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
Compare the site of action with the CD products?
Looking at the colon how products work best?
What are the corticosteroids used for CD?
MOA, ADR, Forms
- Budesonide
- Prednisone
- Prednisolone
MOA: Supress inflammation, modulate immune system, inhibits cytokine production
Form: Parenteral, PO, Rectal
ADR: Hyperglycemia, DLD, osteoporosis, infection, increased appetite, insomnia
Types of immunomodulators?
- Azathioprine
- Mercaptopurine
- Methotrexate
- Cyclosporine
Indications of immunomodulators?
ADR, Dosing
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
What are the monoclonal antibodies for CD?
Indications, ADRs
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
What is the difference between biosimilars and generic?
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
What are the meds used to maintain remission?
- 5-ASA
- Budesonide
- Methotrexate
- Thiopurines (Azathioprine, mercaptopurine) - Lots of ADRs, toxic
- Monoclonal antibodies (TNFa inhibitors)
- Cyclosporine (salvage therapy)
Mild-moderate UC induction tx?
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
Moderate-Severe UC induction tx?
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)
Tx for UC severe or fulminant dx?
- Requires hospitalization
- NPO to promote bowel rest
- Parenteral
- Test for C dif
- Recieve VTE prophylaxis (Lovenox, Heparin, fondaparinux)
- Methylprednisolone IV at dose of 40-60 mg daily is first line agent x 3-5 days before surgery
UC maintenace if remission?
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
Mild to moderate CD?
- Mesalamine as initial therapy (Pentasa to reach small intestine
- Controlled-release budesonide first line option for ileal disease
Moderate to severe CD?
- Require rapid suppresion of inflammation to prevent complications
- Common combo of TNF-a inhibitors with azathiopurine
- PO CS first-line if unresponsive to 5-ASA (prednisone 40-60 mg/d)
* IV if hospitalized and unable to tolerate PO
Tx of severe/fulminant CD?
- Likely requires surgery
- May consider TNF-aI
Tx for CD remission?
- More difficult to achieve and maintain than UC
- TNF-a inhibitors are good maintenance
* Add thiopurine to enhance efficacy and extend the suration of THNF-a inhibitor efficacy
