Chapter 1: GI System Flashcards
Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?
No
What are coeliac patients at increased risk of?
Malabsorption
Vitamin and mineral deficiency - could increase the risk of osteoporosis
What is diverticular disease?
Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain in the absence of inflammation or infection.
Can cause large rectal bleeds
What is the treatment for uncomplicated diverticular disease?
Low residue (fibre) diet and bowel rest
Are antibacterials recommended in uncomplicated diverticular disease?
No unless the patient presents with signs of infection/immunocompromised
What is the treatment for complicated diverticular disease?
Hospital admission, IV antibacterials covering gram negative and anaerobes
Bowel rest
True or false:
There is insufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis
True
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
Avoids the sulfonamide-related side effects of sulfasalazine
Sulfasalazine is a combination of what two compounds?
5-ASA and sulfapyridine
Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects
What compound is mesalazine?
5-ASA
Balsalazide is a pro drug of what?
5-ASA
What are extraintestinal manifestations?
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
- In a patient with a first presentation or single inflammatory Crohn’s exacerbation in a 12 month period, what is used?
- If this is not suitable, or if the patient has right-sided colonic disease, what could be used? When would these not be appropriate and why?
- Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
- Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
When would you add in additional treatment (on top of steroid monotherapy) in a Crohn’s disease exacerbation?
What would you add?
2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced
Azathioprine or mercaptopurine
Is mercaptopurine licensed in severe UC and CD?
No
- What can be added to a steroid to induce remission in a Crohn’s patient?
- If these are not suitable, what could be used?
- Azathioprine
Mercaptopurine can be added but unlicensed
- Methotrexate
What test do you need to do before starting someone on azathioprine or mercaptopurine?
TPMT levels
If activity is deficient, it may not be suitable
What monoclonal antibodies are licensed for Crohn’s?
Adalimumab
Infliximab-can also be used for active fistulating CD
Vedolizumab
- What is used for maintenance of remission for Crohn’s?
2. What would be second line and when would you use this?
- Azathioprine
Mercaptopurine (unlicensed)
- Methotrexate if the patient required it to induce remission, or if azathioprine/mercaptopurine is unsuitable
Should steroids be used for the maintenance of remission for Crohn’s?
No- only to induce remission
What can be used to manage Crohn’s associated diarrhoea?
Loperamide, codeine phosphate, colestyramine
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?
Metronidazole and ciprofloxacin (unlicensed)
If metronidazole is given for fistulating Crohn’s, how long for and what are the associated risks?
1 month (no longer than 3) due to risk of peripheral neuropathy
What is used to control the inflammation in fistulating Crohn’s disease (and continued for maintenance)? How long should they be on this for?
Azathioprine or mercaptopurine (unlicensed) or infliximab
At least 1 year
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon
What type of laxative may be useful for proximal faecal loading in proctitis?
Macrogol containing osmotic laxative
UC
- What is first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis and proctosigmoiditis?
- What would be second line?
- Rectal aminosalicylates. Oral prednisolone should be considered for the treatment of patients with subacute proctitis or proctosigmoiditis.
- Rectal corticosteroid or oral prednisolone
What aminosalicylates have rectal preparations?
Mesalazine or sulfasalazine
What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?
High induction dose of an oral aminosalicylate, with addition of a rectal aminosalicylate or oral beclometasone dipropionate if necessary.
Oral prednisolone alone is recommended for patients who cannot tolerate or who decline aminosalicylates, in whom aminosalicylates are contra-indicated or in patients with subacute left-sided or extensive ulcerative colitis.
Mild to moderate UC:
In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?
No improvements within 4 weeks of initial therapy
If patient is on beclometasone, discontinue this
Why does oral budesonide have fewer systemic side effects than corticosteroids?
It exerts its action topically in the colon
True or false:
Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
True
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects
What should be given in acute severe UC?
IV corticosteroids
IV ciclosporin is an alternative (unlicensed)
Infliximab
Assess for surgery
What monoclonal antibodies are used for acute UC?
Adalimumab, golimumab, infliximab, vedolizumab
What can be used to maintain remission after an acute exacerbation of proctitis/proctosigmoiditis?
Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate
What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?
Low dose oral aminosalicylate
Oral azathioprine or mercaptopurine [unlicensed indications] can be considered to maintain remission, if there has been two or more inflammatory exacerbations in a 12-month period that required treatment with systemic corticosteroids, or if remission is not maintained by aminosalicylates, or following a single acute severe episode.
True or false:
When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
True
What are the red flag side effects of aminosalicylates?
Agranulocytosis Bone marrow disorders Neutropenia Cardiac inflammation Renal impairment - nephrotoxicity
What are the monitoring requirements for aminosalicylates?
Renal function should be monitored before starting treatment, at 3 months, and then annually
Patients should report any unexplained bleeding/bruising/fever/malaise during treatment
FBC - drug should be stopped immediately if any indication of blood dyscrasia (disease/disorder of the blood)
Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?
Within the first 3-6 months of starting treatment
Discontinue if these occur
What should patients on sulfasalazine be aware of if they wear contact lenses?
May stain the lenses yellow/orange
What should a patient be screened for if starting vedolizumab?
TB
Contraindicated in those with TB
What is alverine citrate used for?
GI spasms
Dysmenorrhoea
Why would lactulose not be suitable in a patient with IBS?
Causes bloating
In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?
Linaclotide
What is 1st line for diarrhoea in IBS?
Loperamide
What is co-phenotrope used for and what is a main side effect of it?
Decreases faecal output
Opioid that crosses BBB
Patients on colestyramine long term may need supplements of vitamins A, D, K, and folic acid. Why?
Can intefere with absorption of fat soluble vitamins
What is the advice around taking colestyramine with other drugs?
Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.
What role does teduglutide have in short bowel syndrome?
Teduglutide is an analogue of human glucagon-like peptide-2 (GLP-2), which preserves mucosal integrity by promoting growth and repair of the intestine
In patients with short bowel syndrome/stoma, what kinds of preparations would be unsuitable and why? (hint- types of release)
Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient.
Bran is a type of what laxative?
Bulk forming
Isphaghula husk is a type of what laxative?
Bulk forming
Methylcellulose is a type of what laxative?
Bulk forming (also acts as a faecal softener)
Sterculia is a type of what laxative?
Bulk forming
When is onset of action for bulk forming laxatives?
Within 72 hours
Bisacodyl is what type of laxative?
Stimulant
Sodium picosulfate is what type of laxative?
Stimulant
Senna is what type of laxative?
Stimulant
Docusate sodium is what type of laxative?
Stimulant laxative and faecal softener
What is co-danthramer and co-danthrusate used for and what patient group is it limited to? Why?
Constipation in palliative care
Carcinogenicity and genotoxicity risks
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
What are the warnings associated with liquid paraffin as a lubricant?
Anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.
Should not be taken immediately before going to bed
Lactulose is what type of laxative?
Osmotic
Macrogol is what type of laxative?
Osmotic
What is lubiprostone used for?
What is prucalopride used for?
It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
What is 1st line for short duration constipation where dietary measures have not helped?
If stools are soft but difficult to pass, what would be more appropriate?
1. Bulk forming
- Stimulant laxative
- In patients with opioid induced consitipation, what would be appropriate?
- If these do not work, what can then be used?
- Osmotic laxative and stimulant laxative
Docusate sodium can be used to soften the stools - Naloxegol
Methylnaltrexone bromide
What type of laxative should be avoided in opioid induced constipation?
Bulk forming