Crohn’s Flashcards by Aniqa Rahman

Crohn’s is characterised by ______________ areas of the gastro-intestinal wall with inflammation extending through _____________ layers, ________________ and ______________ of the mucosa, and the presence of ____________; affected areas may occur in any part of the gastro-intestinal tract, interspersed with areas of relatively normal tissue.

thickened

all

deep ulceration

fissuring

granulomas

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What are the different presentations of Crohn’s disease? (3)

Recurrent attacks
Acute exacerbations combined with periods of remission
Less active disease

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What are the symptoms of Crohn’s disease? (5)

Abdominal pain
Diarrhea
Fever
Weight loss
Rectal bleeding

*symptoms depend on site of disease

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What are the complications of Crohn’s disease? (8)

Intestinal strictures
Abscesses in the wall of the intestine or adjacent structures
Fistulae
Anemia
Malnutrition
Colorectal and small bowel cancers
Growth failure and delayed puberty in children
Osteoporosis and fractures

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What are the extra-intestinal manifestations of Crohn’s disease? (5)

Arthritis
Abnormalities of the joints,
Eyes,
Liver,
And skin

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Fistulating Crohn’s disease is a complication that involves the formation of a fistula between the intestine and adjacent structures, such as ______________, _____________, and _____________

perianal skin

bladder

vagina

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Fistulating Crohn’s disease occurs in about __/__ of patients, mostly when the disease involves the ___________ area.

one quarter

ileocolonic

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Treatment of Crohn’s is largely directed at the induction and maintenance of ____________ and the ____________.

remission

relief of symptoms

*The aims of drug treatment are to reduce symptoms and maintain or improve quality of life, while minimising toxicity related to drugs over both the short and long term

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In addition to drug treatment, management options for Crohn’s disease include _____________ and attention to nutrition, which plays an important role in supportive care

Smoking cessation

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Surgery for patients with Crohn’s disease may be considered in certain patients with early disease limited to the _____________ and in ___________ or _____________ active disease

distal ileum

severe

chronic

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A ________________, is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn’s disease in a 12-month period

corticosteroid (either prednisolone or methylprednisolone or intravenous hydrocortisone)

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A corticosteroid (either prednisolone or methylprednisolone or intravenous hydrocortisone), is used to induce remission in patients with ________________ or ________________ of Crohn’s disease in a 12-month period

a first presentation

a single inflammatory exacerbation

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In patients with distal ileal, ileocaecal or right-sided colonic disease, in whom a conventional corticosteroid is unsuitable or contra-indicated, _____________ may be considered

budesonide, an inhale CS (less effective but may cause fewer side-effects than other corticosteroids due to limited systemic exposure)

*aminosalicylates are an alternative option in these patients (less effective than a corticosteroid or budesonide but may be preferred because of fewer side effects

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Which two drugs are the main aminosalicylates?

Sulfasalazine

2. Mesalazine

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Aminosalicylates and budesonide __________ (are/are not) appropriate for treating severe presentations and exacerbations of Crohn’s.

Are NOT

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Add on treatment of Crohn’s is prescribed if there are _______ or more inflammatory exacerbations in a 12-month period, or the ____________ dose cannot be reduced

two

corticosteroid

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Which drugs can be used as add-on treatment in Crohn’s disease? (4)

*added to budesonide or corticosteroid

First-line:

Azathioprine
Mercaptopurine (unlicensed)

Second-line:
3. MTX

Third-line:
4. Biologics under specialist supervision eg adalimumab and infliximab (TNF-a inhibitors)

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In the treatment of Crohn’s disease, ______________ and _____________ can be used as monotherapy or combined with an immunosuppressant although there is uncertainty about the comparative effectiveness and long-term side-effects of therapy

Adalimumab

Infliximab

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Patients who choose not to receive maintenance treatment during remission should be made aware of the symptoms that may suggest a relapse (most frequently _______________, ______________, ____________, and ____________)

unintended weight loss

abdominal pain

diarrhoea

general ill-health

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Which drugs are used for the maintenance of remission in patients with Crohn’s? (2)

Azathioprine or mercaptopurine (unlicensed) monotherapy
MTX in patients who required MTX to induce remission or who cannot tolerate azathioprine or mercaptopurine for maintenance

**CS or budesonide should NOT be used

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Active treatment of acute Crohn’s should be distinguished from preventing relapse. Where as ______________ are the mainstay of treatment for managing acute flares/inducing remission in Crohn’s, ________________ are preferred for maintenance of remission.

Corticosteroids

Azathioprine or mercaptopurine

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_____________ in combination with up to 3 months’ postoperative _____________ [unlicensed indication] should be considered to maintain remission in patients with ileocolonic Crohn’s disease who have had complete macroscopic resection within the previous 3 months

Azathioprine

metronidazole

*Azathioprine alone should be considered for patients who cannot tolerate metronidazole

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________________, _____________, and ______________ are no longer recommended to maintain remission following surgery for Crohn’s disease due to the lack of clinical efficacy

Aminosalicylates

Biologic therapies

Budesonide

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_______________ or _____________ can be used to manage diarrhoea associated with Crohn’s disease in those who do not have colitis

Loperamide hydrochloride

codeine phosphate

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______________ is licensed for the relief of diarrhoea associated with Crohn's disease, esp in patients who have had an ileal resection

Colestyramine (binds bile acids in the bowel to prevent reabsorption); in Crohn’s disease, it decreases diarrhea by normalizing the amount of bowel acid in the bowel esp. for patients who have had ileal resection

Why is colestyramine useful in patients with Crohn’s disease?

Colestyramine binds bile acids in the bowel to prevent reabsorption; in Crohn’s disease, it decreases diarrhea by normalizing the amount of bowel acid in the bowel esp. for patients who have had ileal resection

___________ fistulae are the most common occurrence in patients with fistulating Crohn's disease

Perianal

Is treatment always necessary for perianal fistulae in Crohn’s disease?

Not if they are simple or asymptomatic Treatment is required when fistulae are symptomatic or cause local drainage *surgery may be required in conjunction with medical therapy

______________ or ____________ [unlicensed indications], alone or in combination, can improve symptoms of fistulating Crohn's disease but complete healing occurs rarely

Metronidazole ciprofloxacin

Metronidazole is usually given in the treatment of fistulating Crohn’s disease for 1 month, but no longer than 3 months because of concerns about ______________

peripheral neuropathy

Metronidazole is usually given in the treatment of fistulating Crohn’s disease for __________, but no longer than ____________ because of concerns about peripheral neuropathy

1 month 3 months

Either ______________ or ______________ [unlicensed indications] is used to control the inflammation in fistulating Crohn's disease and they are continued for maintenance.

azathioprine mercaptopurine

__________________ is recommended for patients with active fistulating Crohn's disease who have not responded to conventional therapy (including antibacterials, drainage and immunosuppressive treatments), or who are intolerant of or have contra-indications to conventional therapy

Infliximab (TNF-a inhibitor) *should be used after ensuring that all sepsis is actively draining

_______________, _____________, and _____________ insertion may be appropriate in the treatment of fistulating Crohn’s, particularly before infliximab treatment

Abscess drainage fistulotomy seton

_______________, _____________, or _____________ should be continued as maintenance treatment for at least one year in patients who have been treated for fistulating Crohn’s disease

Azathioprine mercaptopurine infliximab

For the management of non-perianal fistulating Crohn's disease (including entero-gynaecological and enterovesical fistulae) _____________ is the only recommended approach

surgery

In addition to being used in the acute management of Crohn’s disease, sulfasalazine is also used in the management of _____________ and _______________

Ulcerative colitis (acute treatment and maintenance of remission) RA

Sulfasalazine should be prescribed with caution in which patients? (7)

1. Acute porphyrias 2. G6PD deficiency 3. History of allergy 4. History of asthma 5. Risk of hematological toxicity 6. Risk of hepatic toxicity 7. Slow acetylator status

What are the common or very common side effects of aminosalicylates (sulfasalazine and mesalazine)? (7)

1. Arthralgia 2. Cough 3. GI discomfort, diarrhea, N/V 4. Leukopenia 5. Fever 6. Skin reactions 7. Dizziness

What are the common or very common side effects specific to sulfasalazine? (5)

1. Insomnia 2. Stomatitis 3. Altered taste 4. Tinnitus 5. Urine abnormalities

For patients taking aminosalicylates, a blood count should be performed and the drug stopped immediately if there is suspicion of a _________________.

blood dyscrasia; hematological abnormalities usually occur in the first 3-6 months

Aminosalicylates are contraindicated in patients with ______________ hypersensitivity

Salicylate (ie aspirin)

Is sulfasalazine safe to give in pregnancy?

Theoretical risk of neonatal hemolysis in the third trimester; adequate folate supplementation should be given

Is sulfasalazine safe to take while breastfeeding?

Small amount present in milk; theoretical risk of neonatal hemolysis especially in G6PD-deficient infants

Can sulfasalazine be given to patients with hepatic and/or renal impairment?

Cation in hepatic impairment Cation in mild-moderate renal impairment due to risk of toxicity including crystalluria; avoid in severe impairment

___________ function should be monitored before starting an oral aminosalicylate, at 3 months of treatment, and then annually during treatment.

Renal

Renal function should be monitored ____________ an oral aminosalicylate, at ________ months of treatment, and then ___________ during treatment.

Before starting 3 annually

For patients taking sulfasalazine, close monitoring of _______________ is necessary initially, and at monthly intervals during the first 3 months.

full blood counts (including differential white cell count and platelet count)

For patients taking sulfasalazine, close monitoring of full blood counts (including differential white cell count and platelet count) is necessary ____________, and at __________ intervals during the first ____________.

initially monthly 3 months

For patients taking sulfasalazine, ________________ should be performed at monthly intervals for first 3 months

Liver function tests | Also renal function baseline, at 3 months, then annually

Patients receiving aminosalicylates, and their carers, should be advised to report any ______________, ____________, ___________, ___________, ___________, or __________ that occurs during treatment

unexplained bleeding bruising purpura sore throat fever malaise

What can occur to some patients who wear contact lenses when taking sulfasalazine?

Some soft contact lenses may be stained

Caution should be used when prescribing sulfasalazine alongside other drugs that may increase the risk of _____________ or ____________

Hepatotoxicity (eg azoles, INH) Myelosuppression (eg biologics)

Unlike sulfasalazine, mesalazine is not licensed for the treatment of _____________

Crohn’s | Though both are licensed for treatment of ulcerative colitis

Mesalazine is contraindicated in patients with _______________ and _______________

Blood clotting abnormalities Salicylate hypersensitivity

Side effects specific to mesalazine include…. (5)

1. Cholestasis exacerbated 2. Drug fever 3. Flatulence 4. Nephritis 5. Constipation

Is mesalazine safe to use in pregnancy and breastfeeding?

Negligible quantities cross the placenta or present in breast milk (however, monitor breast-fed infants for diarrhea)

Can mesalazine be prescribed to patients with hepatic and/or renal impairment?

Caution in mild to moderate hepatic and renal impairment (like sulfasalazine, risk of crystalluria in renal disease) Avoid in severe hepatic or renal impairment

Azathioprine is metabolised to _____________

mercaptopurine

________________ is metabolised to mercaptopurine

Azathioprine

In addition to being used in the treatment of Crohn’s disease, azathioprine is also indicated in the treatment of ____________, _____________, ______________, _______________, _____________, ______________, _______________, and ____________

``` UC (acute and maintenance) RA that has not responded to other DMARDs Severe SLE and other CTDs Poly myosotis in cases of CS resistance Suppression of transplant rejection Severe refractory eczema (unlicensed) Generalized MG Other autoimmune conditions ```

Manufacturer advises reduce dose of azathioprine to one-quarter of the usual dose with concurrent use of ______________.

allopurinol

What are the contraindications to using azathioprine and mercaptopurine?

Absent or very low TPMT activity

Caution when prescribing azathioprine or mercaptopurine with other drugs that may cause _______________ or increase the risk of _______________

Myelosuppression (eg biologics) Generalized infection (eg live vaccines)

What are the common or very common side effects of azathioprine? (5)

1. Bone marrow suppression 2. Increased risk of infection 3. Leukopenia 4. Pancreatitis 5. Thrombocytopenia

Which side effects of azathioprine may require drug withdrawal? (3)

1. Hypersensitivity 2. Neutropenia and thrombocytopenia 3. Nausea (although moderate nausea may be managed by using divided doses, taking after food, prescribing antiemetics, or temporarily reducing the dose)

Nausea is common early in the course of treatment with azathioprine and usually resolves after a few weeks without an alteration in dose. Moderate nausea can be managed by using _______________, taking doses ______________, prescribing concurrent _______________ or ____________ the dose.

divided daily doses after food antiemetics temporarily reducing

Patients who are allergic to azathioprine are also allergic to ________________

Mercaptopurine

Is azathioprine safe to use during pregnancy and breastfeeding?

Azathioprine is teratogenic in animal studies and has been reported to cause premature birth, low birth-weight, and spontaneous abortion HOWEVER, azathioprine should NOT be stopped in patients who are transplant recipients; use should be supervised during pregnancy by specialist Okay during breastfeeding

Is azathioprine safe to use in patients with hepatic and/or renal failure?

Caution (increased monitoring) in severe liver impairment; reduce dose Reduce dose in renal impairment

What pre-treatment screening is required for patients taking azathioprine?

The enzyme thiopurine methyltransferase (TPMT) metabolises thiopurine drugs (azathioprine, mercaptopurine, tioguanine); the risk of myelosuppression is increased in patients with reduced activity of the enzyme, particularly for the few individuals in whom TPMT activity is undetectable. Manufacturer advises consider measuring TPMT activity before starting azathioprine, mercaptopurine, or tioguanine therapy. Seek specialist advice for those with reduced or absent TPMT activity.

What are the monitoring requirements for patients taking azathioprine? (2)

1. Monitor for toxicity throughout treatment | 2. FBC weekly for the first 4 weeks, then at least every 3 months

Blood tests and monitoring for signs of _________________ are essential in long-term treatment of patients taking azathioprine

myelosuppression

Regarding azathioprine, patients and their carers should be warned to report immediately any signs or symptoms of ________________

bone marrow suppression e.g. inexplicable bruising or bleeding, infection

Is mercaptopurine safe to use during pregnancy and breastfeeding?

Avoid, teratogenic | Discontinue breastfeeding

What monitoring requirements are necessary for patients taking mercaptopurine?

Monitor liver function