Chronic Bowel Disorders

Question 1

What role does antimuscarinics have that make them useful in IBS?

Answer 1

Reduces intestinal motility, relaxes SM

Question 2

What condition is CI in all antispasmodics?

Answer 2

Paralytic ileus, obstruction of ileus

Question 3

What is the difference between proctitis and proctosigmoiditis?

Answer 3

Proctitis is inflammation of rectum and proctosigmoiditis is inflammation of rectum and sigmoid colon

Question 4

What is the recommended drug treatment for a single acute exacerbation of Crohn’s?

Answer 4

Corticosteroid ( prednisolone, methylprednisolone or iv hydrocortisone) to induce remission. If unsuitable or CI budenoside can be used if suffering from distal ileal, ileolocal or right sided disease, alternatively aminosalicylates (sulfasalazine or mesalazine) can be used, they may not be as effective but have less side effects making them more preferable.

Question 5

When should add on therapy be used for Crohn’s?

Answer 5

If there are two or more exacerbations in a 12 month period or corticosteroid cannot be reduced.

Question 6

What add on drug tx can you use in Crohn’s to induce remission alongside corticosteroids?

Answer 6

Azathioprine or mercaptopurine (unlicensed) can be used, if cannot be tolerated or pt has TPMT deficiency, budenoside or methotrexate are other alternatives

Question 7

What other options are available in Crohn’s if conventional therapy fails to induce remission?

Answer 7

Monoclonal antibodies inflIiximab, adalimumab, vedolizumab

Question 8

How do you proceed if a pt refuses maintenance tx for Crohn’s?

Answer 8

Discuss the symptoms that may suggest a relapse, weight loss, ab pains, diarrhoea, general ill health, a follow up plan should be provided including information on how to access healthcare if relapse occurs.

Question 9

What drugs can be used for maintaining remission in Crohn’s?

Answer 9

Azathioprine or mercaptopurine (unlicensed). Methotrexate can only be used if it was also used to induce remission or if intolerant to azathioprine or mercaptopurine.

Question 10

How long should metronidazole be given for in fistulating Crohn’s?

Answer 10

1 month, no longer than 3 due to peripheral neuropathy risk.

Question 11

What are the differences between Crohn’s and UC?

Answer 11

Uc is limited to the colon where as Crohns can occur anywhere between the mouth and anus. Crohns is characterised by patchy deep ulceration, in UC inflammation is more superficial and continuous

Question 12

What tool is used to determine severity of UC and what are the determining factors?

Answer 12

Truelove and Witts’ severity index, frequency of stools, fever,heart rate, haemoglobin levels, blood in stools, ESR.

Question 13

Loperamide can be used to treat diarrhoea associated UC however it is CI in acute UC due to the risk of toxic megacolon, what is this condition?

Answer 13

Rare but life threatening condition caused by infection, chronic bowel disease, ischamia in the colon or cancer, the colon begins to widen which can then cause multiple serious complications including perforation in the colon, sepsis, bleeding, shock.

Question 14

Single daily doses of aminosalicylates can be more effective than multiple daily doses, however in practice multiple daily doses are commonly seen, why is this?

Answer 14

High singular doses have more risk of side effects

Question 15

What is recommended for acute mild-mod UC?

Answer 15

Aminosalicylates with or without a corticosteroid, a combination of oral and rectal aminosalicylates have higher rates of improvement in disease activity. In proctitis and proctosigmoiditis monotherapy with rectal aminosalicylates is more effective than oral. Rectal corticosteroid can be used if aminosalicylate CI or unsuitable, oral corticosterids can be considered if sub acute.

Question 16

When should add on therapy be considered and what is the add on therapy following treatment failure of aminosalicylates in UC?

Answer 16

If there are no improvements within four weeks of initial treatment or if symptoms worsen oral prednisolone can be added.

Question 17

What are the other options if aminosalicylates and oral prednisolone does not control symptoms of mild-mod UC?

Answer 17

If there is still no response after 2-4 weeks consider adding tacrolimus (unlicensed) to induce remission, budenoside multimatrix can also be considered. Alternatively monoclonal antibodies can be used if conventional treatment is not tolerated or CI.

Question 18

How does initial treatment of severe UC differ to mild-mod?

Answer 18

Severe acute UC is life threatening and rerquires immediate hospital admission, IV corticosteroids is used to induce remission, if this is CI, unsuitable or cannot be tolerated, IV ciclsporin (unlicensed) should be used or surgery considered.

Question 19

Whats the next step in treating acute severe UC if initial monotherapy fails to improve symptoms?

Answer 19

If symptoms worsen or do not improve within 72 hours a combinatiion of IV corticosteroid and ciclorsporin should be used with consideration of surgery.

Question 20

What can be used as an alternative for ciclosporin in treating severe UC?

Answer 20

Infliximab, shown to be as effective as ciclosporin.

Question 21

What is the main drug class used in remission of UC?

Answer 21

Aminosalicylates, oral or rectal, alone or in combination

Question 22

When can oral azathiopurine or mercaptopurine be used to maintain remission in UC?

Answer 22

If there has been two or more exacerbations in a 12 month period that required systemic corticosteroids or if remission is not maintained by aminosalicylates or following a single acute severe episode.

Question 23

What counselling points should you share for a patient taking aminosalicylates?

Answer 23

Common S/E include (sulfalazine although less prescribed in IBD can cause discoloration of the urine) GI disturbances and headaches, it is very important to look out for any unexplained bleeding, bruising, fever or malaise as can cause various blood disorders.

Question 24

Mesalazine and sulfalazine are both aminosalicylates used in IBD, why is mesalazine used more in practice than sulfasalazine?

Answer 24

Sulfasalazine contains a sulfapyridine group that causes more side effects.

Question 25

If you are allergic to aspirin is it ok to take aminosalicylates?

Answer 25

No, CI in salicylate hypersensitivity

Question 26

What if any monitoring requirements should be undertaken with aminosalicylates?

Answer 26

Renal function should be monitored before starting oral aminosalicylates, at 3 months after treatment and then annually. In sulfalazine FBC and LFT is necessary, monthly for the first 3 months.