Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Lower gastro-intestinal diseases > Crohns therapeutics > Flashcards

Crohns therapeutics Flashcards

1
Q

What are the five goals of drug therapy in Crohn’s disease?

A

Reduce symptoms
Induce remission
Maintain remission
Improve and maintain the quality of life
Minimise drug toxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the two distinguishable types of Crohn’s disease treatment?

A

Acute treatment- inducing remission after diagnosis or a flare

Maintenance treatment- maintaining remission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Is achieving remission classified by absence of patient symptoms?

A

Previously achieving an absence of patient reported symptoms classified as a patient being in remission.

However, it has been researched that even when a patient has no symptoms, there can still be underlying inflammation.

Use of objective measures such as biological markers are used to classify when remission has been achieved to ensure tight regulation of inflammation and reducing risk of complications.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are some of the objective biological markers that are used to assess degree of inflammation?

A

Endoscopy
CPR
Faecal calprotectin
Imaging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the three Ts that lead to better patient outcomes in controlling IBD?

A

Tight control - achieving clinical and endoscopic remission

Treat to target - adapting treatment based on assessment, to achieve tight control

Timed intervention- early intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Why can’t endoscopies be used regularly in order to monitor inflammation?

A

Unpleasant for the patient
Increased risk of infection
Risk of perforation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What disease and patient considerations affects the choice of therapy in Crohn’s disease?

A

Disease location
Disease activity and severity
Previous response to therapy
Presence of complications or presence of risk factors for complications
Patient characteristics
Risk vs benefit
Cost

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some of the complications present or risk factors for complications which may alter the drug therapy used?

A

Early age of onset
Severe disease
Perianal disease
Recent corticosteroid use at presentation
History of surgical resection
Complicated disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the five main types of Crohn’s disease?

A

Terminal ileal and ileocaecal
Ileitis or Jejunoileitis
Colonic
Gastroduodenal
Perianal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe where terminal ileal/ileocaecal Crohn’s disease is found and the symptoms a patient would experience.

A

Terminal ileal colitis is inflammation at the end of the small intestine, if this inflammation also affects the beginning of the large intestine it is known as ileocecal Crohn’s disease.

Symptoms include:
Pain in the lower right side of the abdomen especially after eating
Diarrhoea, usually without blood
Weight loss
Anaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe where ileitis and jejunoileitis Crohn’s disease is found and the symptoms a patient would experience.

A

Inflammation occurs in the ileum or the jejunum depending on the area of the small intestine that is affected.

Symptoms include:
Abdominal pain
Nutrient deficiencies
Diarrhoea – without blood
Anaemia
Weight loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe where Colonic Crohn’s (Crohn’s colitis) disease is found and the symptoms a patient would experience.

A

Inflammation is affecting only the large intestine

Symptoms include:
Diarrhoea, with blood and mucus
Need to poo very often (frequency) especially if your rectum is inflammed
Need to reach a toilet quickly to poo (urgency)
Feel the need to poo even if the rectum is empty (tenesmus)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe where Gastroduodenal Crohn’s disease is found and the symptoms a patient would experience.

A

Inflammation of the upper GI system- either the oesophagus, stomach or duodenum.

Symptoms include:
Indigestion-like pain
Feeling sick (nausea), sometimes being sick (vomiting)
Loss of appetite and weight loss
Anaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe where perianal Crohn’s disease is found and the symptoms a patient would experience.

A

Inflammation in rectal canal or the anus.

Symptoms include: (mainly complications)
Fissures
Skin tags
Abscesses
Fistulas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are some of the symptoms of oral Crohn’s disease?

A

Also known as orofacial granulomatosis.

Symptoms include:
Swollen lips and red, swollen patches in the corners of the mouth where your lips meet and make an angle.

During flare up of Crohn’s disease in general - patients can also experience mouth ulcers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Which demographic are more likely to have oral Crohn’s disease?

A

Children

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When a patient is diagnosed with Crohn’s disease are they solely just one of the five types?

A

No inflammation associated with Crohn’s disease tends to be patchy throughout the GI tract, so patients can have multiple organs within their GI system affected by inflammation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe the inflammation in Crohn’s disease.

A

The inflammation is patchy with areas of inflammation and normal appearing bowel. The inflammation is also transmural meaning that it extends from the bowel wall to the serosal surface.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the main complications associated with the transmural inflammation of Crohn’s disease?

A

Fibrosis
Strictures
Obstructive symptoms
Intestinal perforation
Perianal disease (formation of fissures, fistulae and abscesses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What percentage of patients with Crohn’s disease have perianal Crohn’s ?

A

1 in 4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What percentage of patients with Crohn’s disease develop fistulae?

A

25-33%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What type of Crohn’s disease are you more likely to develop strictures?

A

Ileitis or jejunoileitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What type of Crohn’s disease is more likely to affect children?

A

Ileitis or jejunoileitis (small intestine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the CDAI tool and how is it used in Crohn’s disease?

A

Crohn’s disease activity index: used to classify the severity of disease

CDAI scores range from 0 to 600.
A score of less than 150 corresponds to relative disease quiescence (remission);

150 to 219, mildly active disease;

220 to 450, moderately active disease;

and greater than 450, severe disease

Limited use in practice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is the Harvey Bradshaw index?

A

It stratifies the severity of Crohn’s disease which consists of a few questions that allows physicians to quickly categorise the severity of Crohn’s disease and detect remission.

26
Q

What are some of the questions used for the Harvey Bradshaw index?

A
  1. Patient’s general well-being (for the previous day)
  2. Abdominal pain (for the previous day)
  3. Number of liquid stools per day (for the previous day)
  4. Abdominal mass
  5. Complications (score 1 per item)

Points are received depending on the patient’s answers

27
Q

What is the scoring system for the Harvey Bradshaw index?

A

Remission: <5
Mild Disease: 5-7
Moderate Disease: 8-16
Severe Disease: >16

28
Q

What does PROMS stand for?

A

Patient reported outcome measures

Impact of disease on the patients quality of life

29
Q

Can HBI and PROMS be used solely for detecting remission?

A

No do not always correlate to underlying inflammation as based on symptoms and patient perceptions and therefore should be used in adjunct with clinical and endoscopic findings and presence of biological markers such as CRP and faecal calprotectin.

29
Q

What does NICE base its guidance on?

A

Rather than severity, guidance is based on the number of exacerbations in 12 months until when deciding use for biological treatments.

30
Q

What does the British gastro-enterology society and the ECCO base its guidance on?

A

Severity of disease

31
Q

What is the potential benefit of having a top down approach?

A

This would include having more potent drugs as the first line treatment to induce rapid control of underlying inflammation and achieve remission and then slowly stepping the patient down especially in those with severe disease and presence of complications.

32
Q

Why may a top down approach not be needed?

A

40% of patients with Crohn’s disease have 10 years of non-complicated disease.

33
Q

What is the NICE guidance for inducing remission in first presentation or a single inflammatory exacerbation of Crohn’s disease in a 12‑month period?

A

Monotherapy of glucocorticoids such as
40mg Prednisolone OD

In patients that can’t have oral:
IV 100mg Hydrocortisone QDS

34
Q

If a patient is contra-indicated to steroids, what does NICE recommend to induce remission? How does this contrast to ECCO?

A

Oral aminosalicylate

Not as effective but fewer side effects
Not recommended according to ECCO due to there being little evidence.

35
Q

Why is withdrawal of steroids used to induce remission crucial?

A

Prevent adrenal insufficiency but also prevents early relapse

36
Q

When is it clinically appropriate and not appropriate to use Budesonide to induce remission?

A

Clinically appropriate: when one or more of
Right sided colonic disease
Distal ileal
Ileal-sequal

Clinically not appropriate:
Severe Crohn’s disease

37
Q

What is the advantages and disadvantages of Budesonide use?

A

Advantages:
Less side effects

Disadvantages:
Not as effective due to poor absorption and clearing via first pass metabolism

38
Q

How does British gastro-enterology society and the ECCO differ in regards to use of Budesonide?

A

States that dose of 9mg of Budesonide once a day is as effective as 40mg Prednisolone once a day in inducing remission in patients with:
Mild to moderate ileal colonic disease (proximal)

Should still not be used in severe disease and dose should be withdrawn appropriately over 1-2 weeks.

39
Q

NICE recommendations for 2 or more inflammatory exacerbations in 12 months and glucocorticoids can’t be tapered?

A

Add on therapy (in addition to conventional steroid):

Azathioprine: 2-2.5mg per kg per day

Mercaptopurine: 1.5mg per kg per day

40
Q

What must be measured before initiating Azathioprine and Mercaptopurine?

A

Assess thiopurine methyltransferase (TPMT) activity

41
Q

How may choice of drug be affected by TPMT levels?

A

Do not offer azathioprine or mercaptopurine if TPMT activity is deficient (very low or absent).

Consider azathioprine or mercaptopurine at a lower dose if TPMT activity is below normal but not deficient (according to local laboratory reference values).

42
Q

When is methotrexate considered for use in inducing remission?

A

Add MTX to a conventional steroid or budesonide in patients who:
Can’t tolerate Azathioprine or Mercaptopurine
Have low TPMT levels

That have had 2 or more inflammatory exacerbations in 12 months and glucocorticoid dose can’t be tapered.

43
Q

What is the time of onset for Azathioprine and Mercaptopurine?

A

8-12 weeks so shouldn’t be used in an acute flare.

44
Q

When is Infliximab and Adalimumab licensed for use?

A

In moderate to severe disease, where the patient has not responded to conventional therapy.

45
Q

When should treatment with Infliximab and Adalimumab be stopped?

A

Until treatment failure or 12 months after initiation but continue if there is evidence of ongoing disease.

46
Q

What may you give Infliximab or Adalimumab with?

A

Immunosuppressant

47
Q

When is Ustekinumab licensed for use in Crohn’s disease?

A

In moderate to severely active disease and where there has been an inadequate, loss of response, patient is contra-indicated or intolerant to conventional therapy or a TNF-alpha inhibitor.

48
Q

When is Vedolizumab licensed for use in Crohn’s disease?

A

In moderate to severe disease
Where a TNF-alpha inhibitor has failed, is contra-indicated, intolerant.

49
Q

What must be discussed with the patient before a decision is made on maintenance therapy?

A

Discussion of the treatment options - both treatment and non-treatment

Risk of inflammatory exacerbations with and without treatment

Potential risk of side effects

50
Q

What points should be discussed with a patient when they have chosen no treatment in maintenance of Crohn’s?

A

Agreement with patient and family members with plans for follow‑up, including the frequency of follow‑up and who they should see

Ensure they know which symptoms may suggest a relapse and should prompt a consultation with their healthcare professional

Ensure they know how to access the healthcare system if they experience a relapse

Discuss the importance of not smoking

51
Q

When should Azathioprine or Mercaptopurine be considered for use in maintaining remission?

A

When the drugs have been previously used alongside conventional glucocorticoids to induce remission.

When they have not been used in patients with risk factors/presence of complications such as:
Early age onset
Perianal disease
Severe presentation

52
Q

In what patients should Methotrexate be considered for use in maintaining remission?

A

In patients who:

Needed methotrexate to induce remission

Have tried but did not tolerate azathioprine or mercaptopurine for maintenance or

have contraindications to azathioprine or mercaptopurine (low TPMT levels)

53
Q

Dosage of Methotrexate for maintenance therapy?

A

15mg to be given s/c once weekly

54
Q

Can steroids be used for maintaining remission?

A

No only for inducing remission, increase in adverse events

Aminosalicylates should also not be used

55
Q

When does the British gastro-enterology society and ECCO recommend use of biologics in maintenance therapy?

A

Adalimumab, Infliximab, Ustekinumab, Vedolizumab are recommended for use when they were used at induction or refractory to immunomodulating therapy.

56
Q

How many people with Crohn’s disease will need to undergo surgery at some point?

A

8 in 10

57
Q

What are the reasons for requiring surgery in Crohn’s disease?

A

Poor response to drugs
Need for nutritional treatment
Strictures
Fistulas or abscesses
Bowel cancer
Toxic megacolon
Perforation

58
Q

When is surgery considered to be a treatment option?

A

Early on as an alternative to medication for patients with Crohn’s refined to distal ileum.

59
Q

Which drugs are used to maintain remission after surgery?

A

To maintain remission in people with ileocolonic Crohn’s disease who have had complete macroscopic resection within the last 3 months, consider azathioprine in combination with up to 3 months’ postoperative metronidazole.

Consider azathioprine alone for people who cannot tolerate metronidazole.

60
Q

Which drugs should not be used for maintaining remission after surgery?

A

Biologics or Budesonide

Lower gastro-intestinal diseases (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions