Clinical Pharmacy III

Question 1

ABC of IBS =

Answer 1

Abdominal pain or discomfort

Bloating

Change in bowel habit

Question 2

Characteristic of the change in bowel habit of IBS.

Answer 2

Diarrhoea episodes after a constipated period

Question 3

Symptoms of IBS

Answer 3

Abdominal pain or discomfort

Bloating

Diarrhoea episodes after a constipated period

Worse with eating -> can identify causative food

Rectal mucus, no dark blood

Legarthy, nausea (limit vomitting)

Back pain, headahces and baller problems

Question 4

Blood test result of IBS

Answer 4

Normal full blood count

Normal ESR and CRP levels

Negative IgAtTGA

Histology result normal

Question 5

How is IBS diagnosed?

Answer 5

Presence of ABCs for at least 6 months

Blood test and history test

Question 6

What diet of IBS patients should be monitored?

Answer 6

Fibre intake

Avoid eating insoluble fibre, encourage highly soluble fibre

Question 7

How is IBS treated?

Answer 7

Focus on control symptoms rather than treating the cause

Lifestyle advice is important

Pharmacological therapy

Question 8

What drugs are used to manage the symptoms of IBS?

Answer 8

Consider antispasmodic agents

Consider laxatives

Consider loperamide or bulk-forming agents

Adjust dose according to response (stool consistency)

Question 9

Give examples of some antispasmodic agents used for IBS.

Answer 9

Hyoscine

Mebeverine

Alverine

Peppermint oil

Question 10

What laxatives should be avoided in IBS?

Answer 10

Lactulose - exacerbate bloating

Question 11

Aim of IBS management

Answer 11

Well-formed stool - type 4 class in Bristol stool form scale

Question 12

Risk factors of coeliac disease.

Answer 12

Genetics

Autoimmune conditions like T1DM or autoimmune thyroid disease

Question 13

Causes of coeliac disease

Answer 13

Autoimmune conditions

Immune response to gluten

Question 14

Pathology of coeliac disease

Answer 14

Chronic inflammation -> damage to lining of small intestines

Reduced villie surface areas -> reduced absorption of nutrients

Question 15

Complications associated with coeliac disease

Answer 15

Cancer - higher risk of mutations

Anaemia

Osteoporosis - insufficient of Ca and vitD absorbed

Dermatitis herpetiformis

Other autoimmune disorders related to liver and thyroids

Question 16

What is dermatitis herpetiformis?

Answer 16

Skin conditions

Characteristics of symmetrical outburst

Any locations on body

Red raised skin patches and lesions

Question 17

How can coeliac disease can cause osteoporosis?

Answer 17

Malabsorption of vit D and calcium ions

Question 18

Symptoms of coeliac disease

Answer 18

Persistent and unexplained GI symptoms

Steatorrhoea (diarrhoea with fat secretion)

Prolonged fatigue

Unexplained weight loss

Severe or persistent mouth ulcers

T1DM

Autoimmune thyroid disease

First-degree relative with coeliac disease

Question 19

Explain why mouth ulcers are present in coeliac disease

Answer 19

suggested to be due to malnutrition, immyne system activation and inflammation

Question 20

What results of blood tests and histology that can confirm coeliac disease?

Answer 20

Positive results of IgA and IgATGA

Low inflammatory marker

Histology confirm a villous atrophy of intestinal mucosa

Question 21

What is the distinctive characteristic of coeliac disease?

Answer 21

Histology and biopsy confirm villous atrophy of intestinal mucosa

Question 22

What cautions should be taken during diagnosis of coeliac disease?

Answer 22

Patients should maintain normal diet until after diagnosis

MUST NOT exclude gluten during this time

Question 23

Management of coeliac disease.

Answer 23

Long-term adherence to a gluten-free diet

Question 24

What food must coeliac patients avoid?

Answer 24

Based on wheat, barley and rye - bread, flour, cakes, pastries and biscuit

Contain wheat, barley or rye as fillers of flavouring - sausage, ready meals, soup, some sauces

Can be contaminated with gluten - oats, items fried in the same oil

Dietery itmes that contain malt - beers`

Question 25

Two most common forms of IBD

Answer 25

Crohn's Disease Ulcerative Colitis

Question 26

Crohn's disease and ulcerative colitis, which one is more common?

Answer 26

Ulcerative colitis are twice more common

Question 27

What are the three types of ulcerative colitis?

Answer 27

Extensive colitis - continous infallamtion of whole colon Distal colitis - inflammation of descending colon and rectum Procitis - inflammation of rectal lining

Question 28

Inflammation pattern of Crohn's Disease

Answer 28

Not continous, patched through the whole GI tract

Question 29

Differences between inflammatory characteristic of ulcerative colitis and Crohn's disease

Answer 29

Ulcerative colitis: only at mucosal level Crohn's disease: inflammation of full thickness of bowel wall Can be confirmed by histology

Question 30

Stool pattern between ulcerative colitis and Crohn's disease

Answer 30

Ulcerative colitis: Diarrhoea more severe - always have blood, mucus and pus Crohn's disease: Steatorrhoea or containing blood or constipated

Question 31

Extraintestinal abdominal features in ulcerative colitis and Crohn's disease

Answer 31

Ulcerative colitis: none Crohn's disease: fatty liver, renal stones or adhesion

Question 32

Development of fistulas in ulcerative colitis and crohn's disease:

Answer 32

ulcerative colitis: absence crohn's disease: present

Question 33

Onset of symptoms - ulcerative colitis and crohn's disease

Answer 33

ulcerative colitis: sudden, occassionally severe crohn's disease: slow and steady, can be acute

Question 34

Pain sensation - ulcerative colitis and crohn's disease

Answer 34

ulcerative colitis: lower abdominal pain + moderate-to-severe, with fever and tachycardia crohn's disease: collicky, like appendicitis

Question 35

Mouth ulcers - ulcerative colitis and crohn's disease

Answer 35

ulcerative colitis: rarely crohn's disease: common

Question 36

Perianal abscesses - ulcerative colitis and crohn's disease

Answer 36

ulcerative colitis: absence crohn's disease: present

Question 37

Complications - ulcerative colitis and crohn's disease

Answer 37

Both have similar complications: affect eyes, joints, skin, spine, fatty liver Crohn's disease: gallstones, renal stones and fistula development

Question 38

Risks factors of IBD.

Answer 38

Smoking (suggested) Family history Appendectomy Use of NSAIDs and oral contraceptive pills (suggested)

Question 39

Principles of IBD management

Answer 39

Induce and maintain remission Nutrition supply Pain relief Symptomatic control of constipation and diarrhoea Manage fatigue Surgery for fistula and abscesses Treat dyspepsia (if present)

Question 40

What drugs are given for pain relief of IBD?

Answer 40

1st-line: paracetamol 2nd-line: can add opioids, but required specialist Must not use NSAIDs

Question 41

What drug that must not be given to control symptom of IBD?

Answer 41

Loperamide cannot be used in Crohn's disease Risk of developing toxic megacolon (severe inflammation and dilation of colon) - life-threatening

Question 42

Pharmacological treatment of Crohn's disease (NICE guidelines)

Answer 42

To induce remission: 1st-line: Monotherapy of prednisolone, methylprednisolone or IV hydrocortisone 2nd-line: budesonide or 5-ASA agents (sulfazadine, mesalazine) 3rd-line: add azathioprine or mercaptopurine 4th-line: add methotrexate 5th-line: biological therapy like infliximab or adalimumab To maintain remission: 1st-line: azathioprine or mercaptopurine 2nd-line: methotrexate

Question 43

What tools are used to assess the classification of ulcerative colitis to manage?

Answer 43

Truelove and Witt's severity index

Question 44

What are the four classes of ulcerative colitis used to dictate the management?

Answer 44

Mild-moderate proctitis Mild-moderate protosigmoiditis + left-sded ulcerative colitis Mild-moderate extensive colitis Acute severe ulcerative colitis

Question 45

Pharmacological treatment - mild-to-moderate proctitis

Answer 45

To induce remission: 1st-line: topical 5-ASA, (If not achieved within 4 weeks: add oral 5-ASA) 2nd-line: add topical corticosteroid or PO prednisolone If develop to moderate-to-severe: introduce immunotherapy and biologicals To maintain remission: - Topical 5-ASA - PO 5-ASA + topical 5-ASA - PO 5-ASA If not work: 1st-line: oral azathioprine OR oral mercaptopurine 2nd-line: oral 5-ASA

Question 46

Pharmacological treatment - mild-to-moderate proctosigmoiditis.

Answer 46

To induce remission: 1st-line: topical 5-ASA, (If not achieved within 4 weeks: add oral 5-ASA) 2nd-line: add topical corticosteroid or PO prednisolone If develop to moderate-to-severe: introduce immunotherapy and biologicals To maintain remission: - Topical 5-ASA - PO 5-ASA + topical 5-ASA - PO 5-ASA If not work: 1st-line: oral azathioprine OR oral mercaptopurine 2nd-line: oral 5-ASA

Question 47

Pharmacological treatment - mild-to-moderate left-sided ulcerative colitis.

Answer 47

To induce remission: 1st-line: topical 5-ASA, (If not achieved within 4 weeks: add oral 5-ASA) 2nd-line: add topical corticosteroid or PO prednisolone If develop to moderate-to-severe: introduce immunotherapy and biologicals To maintain remission: low maintenance PO 5-ASA If not work: 1st-line: oral azathioprine OR oral mercaptopurine 2nd-line: oral 5-ASA

Question 48

Pharmacological treatment - mild-to-moderate extensive ulcerative colitis.

Answer 48

To induce remission: 1st-line: topical 5-ASA + high dose PO 5-ASA (If not achieved within 4 weeks, use high dose PO + oral steroid) 2nd-line: oral prednisolone If develop to moderate-to-severe: introduce immunotherapy and biologicals To maintain remission: low maintenance PO 5-ASA If not work: 1st-line: oral azathioprine OR oral mercaptopurine 2nd-line: oral 5-ASA

Question 49

Pharmacological treatment - mild-to-moderate acute severe ulcerative colitis.

Answer 49

Admit to hospital + MDT meetings to see need surgery To induce remission: 1st step: IV corticosteroids -> if not possible, IV ciclosporin OR surgery 2nd step (after 72 hours): if no improvement -> IV corticosteroid + IV ciclosporin OR surgery To maintain remission: 1st-line: oral azathioprine OR oral mercaptopurine 2nd-line: oral 5-ASA

Question 50

When will PO azathioprine or PO mercaptopurine be used to maintain remission of ulcerative colitis?

Answer 50

5-ASA not effective 2 or more exacerbation within 12 months that require systemic corticosteroid

Question 51

Describe the meaning and factors associated with Truelove and Witt's severity index for ulcerative colitis

Answer 51

Check notes

Question 52

What are the special precautions for the use of azathioprine and mercaptopurine?

Answer 52

Assess thiopurine methyltransferase (TPMT) activity before giving If deficient -> must not give If low but NOT deficient -> low dose

Question 53

Why is rectal treatment suitable for IBD?

Answer 53

Suppository target rectum -> suitable for proctitis Foam targets sigmoid colon -> suitable for proctosigmoiditis Enema targets descending colon + distal part of transverse colon -> suitable for left-sided colitis.