Crohn's disease

Question 1

Inflammatory bowel disease (IBD) is an umbrella term used describe which two conditions?

Answer 1

Crohn’s and Ulcerative colitis

Question 2

Sulfasalazine is a combination of 5-aminosalicylic acid (‘5-ASA’) and sulfapyridine used in the management of chronic bowel disorders. what is the role of sulfapyridine?

Answer 2

Sulfapyridine acts only as a carrier to the colonic site of action - It causes side-effects.

Question 3

List the sulfonamide-related side effects of Sulfasalazine

Answer 3

1) Skin rash
2) Itching
3) Headache
4) Dizziness
5) Diarrhoea

Question 4

1) What are the benefits of the newer aminosalicylates, mesalazine, balsalazide and olsalazine?
2) What are disadvantages of these drugs?

Answer 4

1) Sulfonamide-related side-effects of sulfasalazine are avoided
2) 5-ASA alone can cause side-effects including blood disorders and lupus-like syndrome also seen with sulfasalazine

Question 5

Methotrexate can be given to dampen the immune response in chronic bowel disorders. What should be given to reduce the possibility of methotrexate toxicity?

Answer 5

Folic acid usually once weekly on a different day to the methotrexate

Question 6

Which part of the GI tract is affected in crohns?

Answer 6

May occur in any part of the GI tract, interspersed with areas of relatively normal tissue

Question 7

What does the disease characteristically look like in the GI tract?

Answer 7

1) Thickened areas of the GI wall with inflammation extending through all layers
2) Deep ulceration and fissuring of the mucosa
3) Presence of granulomas

Question 8

In crohns symptoms depend on the site of disease, what are the common symptoms of crohns?

Answer 8

1) Abdominal pain
2) Diarrhoea
3) Fever
4) Weight loss
5) Rectal bleeding

Question 9

List some of the Possible complications of Crohn’s disease (7)

Answer 9

1) Intestinal strictures
2) Abscesses in the wall of the intestine
3) Fistulae
4) Anaemia
5) Malnutrition
6) Colorectal and small bowel cancers
7) Growth failure and delayed puberty in children

Question 10

What are the most common extra-intestinal manifestations of Crohn’s disease? (occurring outside the intestines) (3)

Answer 10

1) Arthritis
2) Abnormalities of the joints, eyes, liver and skin
3) Secondary osteoporosis- those at greatest risk should be monitored for osteopenia and assessed for the risk of fractures

Question 11

What are the characteristics of fistulating Crohn’s disease which part of the GI tract does it involve?

Answer 11

1) Formation of a fistula between the intestine and adjacent structures, such as perianal skin, bladder, and vagina
2) Involves the ileocolonic area

Question 12

What are the non-drug treatment and supportive care advice provided to those with crohns? (3)

Answer 12

1) Surgery may be considered in early disease limited to the distal ileum and in severe or chronic active disease
2) Smoking cessation and attention to nutrition
3) Assessing osteoporosis risk

Question 13

What is the monotherapy treatment option In patients presenting with crohns for the first time or in those who have had a single inflammatory exacerbation in a 12-months?

Answer 13

1) A corticosteroid (either prednisolone or methylprednisolone or IV hydrocortisone), is used to induce remission
(Aminosalicylates- mesalazine, sulfasalazine may be considered for a first presentation, if corticosteroids C/I)

Question 14

1) In patients with distal ileal, ileocaecal or right-sided colonic disease, in whom a conventional corticosteroid are contra-indicated what drugs can be used?
2) What are the advantages and disadvantages of using these drug?

Answer 14

1) Budesonide or Aminosalicylates
2a) Budesonide: less effective but may cause fewer side-effects than other corticosteroids, as systemic exposure is limited
b) Aminosalicylates: less effective than a corticosteroid or budesonide, but may be preferred due to less SE

Question 15

When is add-on therapy prescribed in crohns?

Answer 15

If there are two or more inflammatory exacerbations in a 12-month period, or the corticosteroid dose cannot be reduced

Question 16

1) Which drugs can be used as add-on therapy in combination with corticosteroid or budesonide to
induce remission? (2)
2) Why should these drugs not be used in patients who are deficient in thiopurine methyltransferase (TPMT)?

Answer 16

1) Azathioprine or mercaptopurine
2) TPMT- metabolises azathioprine and mercaptopurine; If deficient in this enzyme there is a risk of developing severe, potentially life-threatening bone marrow toxicity

Question 17

In patients who cannot tolerate azathioprine or mercaptopurine as add-on therapy, which drug can be considered?

Answer 17

Methotrexate can be added to a corticosteroid

Question 18

1) Monoclonal antibody therapies, adalimumab and infliximab, are options for the treatment of severe, active Crohn’s disease. when should these drugs be considered?
2) Adalimumab is another mAb, when would this be considered?

Answer 18

1) Inadequate response to conventional therapies or C/I / intolerant to conventional therapy.
2) when therapy with adalimumab and infliximab fails

Question 19

Some patients choose not to receive maintenance treatment for crohns. In these individuals the symptoms that suggest relapse need to be communicated. outline the symptoms that might indicate a relapse?

Answer 19

1) Unintended weight loss
2) Abdominal pain
3) Diarrhoea
4) General ill-health

Question 20

Which drugs can be used as monotherapy to maintain remission in crohns?

Answer 20

1) Azathioprine or mercaptopurine- if they were previously used with a corticosteroid to induce remission
2) Methotrexate- only in patients who required methotrexate to induce remission, or who are intolerant to the above.

Question 21

Which drugs should not be used to maintain remission in crohns?

Answer 21

Corticosteroids or budesonide should not used

Question 22

Which drugs can be used to manage diarrhoea associated with Crohn’s disease ?

Answer 22

1) Loperamide or codeine

2) Colestyramine is licensed for the relief of diarrhoea associated with Crohn’s disease

Question 23

1) Which two antibiotics can be given in fistulating Crohn’s disease to improve symptoms?
2) How long should these be given for?

Answer 23

1) Metronidazole or ciprofloxacin -alone or in combination
2) Metronidazole is usually given for 1 month, but no longer than 3 months because of concerns about peripheral neuropathy

Question 24

1) Which drugs can be used to control the inflammation in fistulating Crohn’s disease?
2) How long should these drugs be taken for?

Answer 24

1a) Azathioprine or mercaptopurine
1b) Infliximab is recommended for patients with active fistulating Crohn’s disease who have not responded to conventional therapy (including antibacterials, drainage and immunosuppressive treatments)
2) Continued as maintenance treatment for at least one year.