Clinical Pharmacy III Flashcards
IBS, IBD, Coeliac Disease
ABC of IBS =
Abdominal pain or discomfort
Bloating
Change in bowel habit
Characteristic of the change in bowel habit of IBS.
Diarrhoea episodes after a constipated period
Symptoms of IBS
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
Blood test result of IBS
Normal full blood count
Normal ESR and CRP levels
Negative IgAtTGA
Histology result normal
How is IBS diagnosed?
Presence of ABCs for at least 6 months
Blood test and history test
What diet of IBS patients should be monitored?
Fibre intake
Avoid eating insoluble fibre, encourage highly soluble fibre
How is IBS treated?
Focus on control symptoms rather than treating the cause
Lifestyle advice is important
Pharmacological therapy
What drugs are used to manage the symptoms of IBS?
Consider antispasmodic agents
Consider laxatives
Consider loperamide or bulk-forming agents
Adjust dose according to response (stool consistency)
Give examples of some antispasmodic agents used for IBS.
Hyoscine
Mebeverine
Alverine
Peppermint oil
What laxatives should be avoided in IBS?
Lactulose - exacerbate bloating
Aim of IBS management
Well-formed stool - type 4 class in Bristol stool form scale
Risk factors of coeliac disease.
Genetics
Autoimmune conditions like T1DM or autoimmune thyroid disease
Causes of coeliac disease
Autoimmune conditions
Immune response to gluten
Pathology of coeliac disease
Chronic inflammation -> damage to lining of small intestines
Reduced villie surface areas -> reduced absorption of nutrients
Complications associated with coeliac disease
Cancer - higher risk of mutations
Anaemia
Osteoporosis - insufficient of Ca and vitD absorbed
Dermatitis herpetiformis
Other autoimmune disorders related to liver and thyroids
What is dermatitis herpetiformis?
Skin conditions
Characteristics of symmetrical outburst
Any locations on body
Red raised skin patches and lesions
How can coeliac disease can cause osteoporosis?
Malabsorption of vit D and calcium ions
Symptoms of coeliac disease
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
Explain why mouth ulcers are present in coeliac disease
suggested to be due to malnutrition, immyne system activation and inflammation
What results of blood tests and histology that can confirm coeliac disease?
Positive results of IgA and IgATGA
Low inflammatory marker
Histology confirm a villous atrophy of intestinal mucosa
What is the distinctive characteristic of coeliac disease?
Histology and biopsy confirm villous atrophy of intestinal mucosa
What cautions should be taken during diagnosis of coeliac disease?
Patients should maintain normal diet until after diagnosis
MUST NOT exclude gluten during this time
Management of coeliac disease.
Long-term adherence to a gluten-free diet
What food must coeliac patients avoid?
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`
Two most common forms of IBD
Crohn’s Disease
Ulcerative Colitis
Crohn’s disease and ulcerative colitis, which one is more common?
Ulcerative colitis are twice more common
What are the three types of ulcerative colitis?
Extensive colitis - continous infallamtion of whole colon
Distal colitis - inflammation of descending colon and rectum
Procitis - inflammation of rectal lining
Inflammation pattern of Crohn’s Disease
Not continous, patched through the whole GI tract
Differences between inflammatory characteristic of ulcerative colitis and Crohn’s disease
Ulcerative colitis: only at mucosal level
Crohn’s disease: inflammation of full thickness of bowel wall
Can be confirmed by histology
Stool pattern between ulcerative colitis and Crohn’s disease
Ulcerative colitis: Diarrhoea more severe - always have blood, mucus and pus
Crohn’s disease: Steatorrhoea or containing blood or constipated
Extraintestinal abdominal features in ulcerative colitis and Crohn’s disease
Ulcerative colitis: none
Crohn’s disease: fatty liver, renal stones or adhesion
Development of fistulas in ulcerative colitis and crohn’s disease:
ulcerative colitis: absence
crohn’s disease: present
Onset of symptoms - ulcerative colitis and crohn’s disease
ulcerative colitis: sudden, occassionally severe
crohn’s disease: slow and steady, can be acute
Pain sensation - ulcerative colitis and crohn’s disease
ulcerative colitis: lower abdominal pain + moderate-to-severe, with fever and tachycardia
crohn’s disease: collicky, like appendicitis
Mouth ulcers - ulcerative colitis and crohn’s disease
ulcerative colitis: rarely
crohn’s disease: common
Perianal abscesses - ulcerative colitis and crohn’s disease
ulcerative colitis: absence
crohn’s disease: present
Complications - ulcerative colitis and crohn’s disease
Both have similar complications: affect eyes, joints, skin, spine, fatty liver
Crohn’s disease: gallstones, renal stones and fistula development
Risks factors of IBD.
Smoking (suggested)
Family history
Appendectomy
Use of NSAIDs and oral contraceptive pills (suggested)
Principles of IBD management
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)
What drugs are given for pain relief of IBD?
1st-line: paracetamol
2nd-line: can add opioids, but required specialist
Must not use NSAIDs
What drug that must not be given to control symptom of IBD?
Loperamide cannot be used in Crohn’s disease
Risk of developing toxic megacolon (severe inflammation and dilation of colon) - life-threatening
Pharmacological treatment of Crohn’s disease (NICE guidelines)
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
What tools are used to assess the classification of ulcerative colitis to manage?
Truelove and Witt’s severity index
What are the four classes of ulcerative colitis used to dictate the management?
Mild-moderate proctitis
Mild-moderate protosigmoiditis + left-sded ulcerative colitis
Mild-moderate extensive colitis
Acute severe ulcerative colitis
Pharmacological treatment - mild-to-moderate proctitis
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
Pharmacological treatment - mild-to-moderate proctosigmoiditis.
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
Pharmacological treatment - mild-to-moderate left-sided ulcerative colitis.
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
Pharmacological treatment - mild-to-moderate extensive ulcerative colitis.
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
Pharmacological treatment - mild-to-moderate acute severe ulcerative colitis.
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
When will PO azathioprine or PO mercaptopurine be used to maintain remission of ulcerative colitis?
5-ASA not effective
2 or more exacerbation within 12 months that require systemic corticosteroid
Describe the meaning and factors associated with Truelove and Witt’s severity index for ulcerative colitis
Check notes
What are the special precautions for the use of azathioprine and mercaptopurine?
Assess thiopurine methyltransferase (TPMT) activity before giving
If deficient -> must not give
If low but NOT deficient -> low dose
Why is rectal treatment suitable for IBD?
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.
