Chrons disease

Question 1

What are the aims of therapy?

Answer 1

Decrease symptoms
Induce and maintain remission
Improve quality of life
Minimise drug related toxicty

Question 2

What factors influence the choices of therapy for CD patients?

Answer 2

Location
Activity and severity
Previous response to therapy
Presence of complications
Risk factors, patient characteristics, risks v benefits, costs

Question 3

What is the CDAI?

Answer 3

The chron’s disease activity index
Values below 150 = remission
Values 300+ = severe active disease

Question 4

What does a value of below 150 on the CDAI index indicate?

Answer 4

Remission

Question 5

What are the risk factors for progression and complications of cd?

Answer 5

• Early age onset
• corticosteroid use at presentation
• severe symptoms at presentation
• perianal disease
• surgical resection

Question 6

What are the first-line treatments for inducing remission in CD?

Answer 6

• Monotherapy with traditional glucocorticoid e.g. Prednisolone oral 40mg OD, tapering of 5mg weekly
  or hydrocortisone IV 100mg QDS
• If refuse or CId in conventional steroids, Budesonide can be used
  e.g. in patients who have ileocecal CD- IT IS LESS EFFECTIVE BUT HAS LESS SiDE EFFECTS- POORLY ABSORBED AND CLEARED BY FIRST PASS METABOLISM
• If steroids CId, can use aminosalicylates- less effective but fewer side effects.
• Consider adding mercaptopurine or azathioprine to steroid or budesonide if,
  2+ inflammatory exacerbations in 12 months
  OR
  Glucocorticoid dose cant be tapered
• Consider adding methotrexate to glucocorticoid or budesonide if:
  Patients cant tolerate mercaptopurine or azathioprine
• Or low TPMT activty- Thiopurine methyltransferase= an enzyme that breaks down (metabolizes) a class of drugs called thiopurines

Question 7

When may monoclonal antibodies be used in CD treatment?

Answer 7

Infliximab or adalimumab (anti-tnf)
May be used in moderate-severe disease that is not responding to conventional therapies
- Need a planned course of treatment given until fails or after 12 months since initiation
- May give in combination with an immunosupressant e.g. mercaptopurine/azathioprine/methotrexate

• Ustekinumab can be used where conventional therapies or anti- TNF inhibitors inadequate
• Vedolizumab- in moderate-severe chrons where a TNF inhibitor is failed/CId/not tolerated

Question 8

What are the options for maintaining remission in CD patients?

Answer 8

TREATMENT:
- Offer azathioprine or mercaptopurine where previously used in induction strategy or consider for those with adverse prognostic factors e.g. early age onset, perianal disease
- consider methotrexate- if was on at induction or did not tolerate/CId Azathioprine or mercaptopurine
- DONT offer steroids or aminosalicyclates for maintenance!

NO TREATMENT:
- Make plans to follow up the patient
- Educate on relapse symptoms (weight loss, abdominal pain, diarrhoea), actions and contacts
- Smoking cessation

Question 9

What drug may be given to maintain remission following surgery?

Answer 9

After macroscopic resection within last 3 months- consider azathioprine in combination with metronidazole for up to 3 months post-op
- If metronidazole is not tolerated, can give azathioprine alone