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Pharmacy Pre-Reg > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Difference between Crohn’s and Colitis?

A

Crohn’s: Can affect anywhere in GIT, inflammation can appear as patchy (skip lesions)

Colitis: Usually starts from rectum and progresses as continuous inflammation through large bowel

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2
Q

Types of colitis? (4)

A

Proctitis
Proctosigmoiditis
Left-sided (distal) colitis
Pancolitis

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3
Q

Which formulation would you use for each type of colitis?

A

Suppository - Proctitis
Foam Enema - Proctosigmoiditis
Liquid Enema - Distal colitis
Oral + Topical - Pan colitis

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4
Q

What would you use to induce remission for first presentation or single exacerbation (in 12 month period) of Crohn’s?

A

High dose corticosteroids - Prednisolone, methylprednisolone, hydrocortisone

Budesonide (if other corticosteroids are not tolerated)

Consider aminosalicylates if both the above unavailable (minimal evidence for efficacy)

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5
Q

What could be used as adjunct therapy to induce remission in Crohn’s? (3)

What are the clinical requirements for starting these?

A

Azathioprine or mercaptopurine
Methotrexate (if thiopurines not tolerated)

Experiencing 2 or more exacerbations per year or unable to taper corticosteroid dose

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6
Q

What should be checked prior to starting thiopurines?

How does this affect dosing?

A

TPMT activity

If below normal, consider lowering dose
If deficient, do not offer thiopurines

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7
Q

What should be excluded when a patient presents with an IBD flare up?

What tests should be carried out? (2)

A

Infectious cause of diarrhoea

Faecal calprotectin - Sign of active inflammation
Stool cultures

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8
Q

What would be last line treatment for severe active Crohn’s disease and when would this be appropriate?

A

Biologics - Infliximab, Adalimumab, Ustekinumab, Vedolizumab

If patient has not responded to conventional treatment (corticosteroids, immunosuppressants) and there is clear diagnosis of active disease

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9
Q

What should be checked 6-weeks after commencing treatment with thiopurines?

A

6-TGN levels (active metabolite of azathioprine/mercaptopurine)

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10
Q

What could be used if thiopurine metabolite levels are subtherapeutic?

What adjustments should be made?

A

Concomitant allopurinol

One-quarter of the usual dose of azathioprine/mercaptopurine should be used

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11
Q

What would you use to induce remission of proctitis?

A

Topical aminosalicylate

Oral add-on if no response in 4 weeks or monotherapy for patients who decline topical treatment

Oral or topical corticosteroids if still no response or aminosalicylates not tolerated

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12
Q

What would you use to induce remission of proctosigmoiditis?

A

Topical aminosalicylate

High dose oral add-on if no response in 4 weeks or switch to high dose oral preparation and use short course of topical aminosalicylate

High dose oral aminosalicylate if topical preparation declined

Oral or topical corticosteroids if still no response or aminosalicylates not tolerated/declined

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13
Q

What would you use to induce remission of pancolitis?

A

High dose oral aminosalicylate and topical preparation

If no response in 4 weeks, stop topical preparation and use short-term course of oral corticosteroids with HD oral aminosalicylate

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14
Q

What are the Truelove and Witts’ severity index for acute severe colitis? (6)

A

6+ bowel movements a day with systemic upset (*)

Visible blood in stools

  • Pyrexia (37.8+)
  • HR >90bpm
  • Anaemia
  • Erythrocyte sedimentation rate >30mm/hour
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15
Q

What is the first step in treatment of acute severe colitis?

A

IV corticosteroids

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16
Q

When would IV ciclosporin be considered as an adjunct in acute severe colitis? (2)

A

If little to no response to IV corticosteroids within 72 hours of starting treatment

If symptoms worsen whilst on IV corticosteroids

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17
Q

What can be used as an alternative to ciclosporin in acute severe colitis?

What is the criteria for this?

A

Infliximab

If ciclosporin is contraindicated or clinically inappropriate

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18
Q

How is remission maintained in each type of ulcerative colitis?

A

Proctitis/Proctosigmoiditis - Topical aminosalicylate (daily or intermittent) +/- oral aminosalicylate (daily or intermittent)

Distal/Pancolitis - Low maintenance dose oral aminosalicylate

19
Q

When would a thiopurine be considered in maintaining remission of ulcerative colitis? (3)

A

2 or more exacerbations in 12 months requiring treatment with systemic corticosteroids

Remission not maintained with aminosalicylates

After a single episode of acute severe colitis

20
Q

What is used to maintain remission in Crohn’s disease? (3)

A

Azathioprine
Mercaptopurine
Methotrexate

21
Q

When would methotrexate be used to maintain remission in Crohn’s disease? (3)

A

If used to induce remission

If thiopurines not tolerated

If thiopurines contraindicated (e.g. TPMT deficiency)

22
Q

What is the standard dose of azathioprine for maintenance of remission of Crohn’s/UC?

A

2-2.5mg/kg daily

23
Q

What is the standard dose of mercaptopurine for maintenance of remission of Crohn’s/UC?

A

1-1.5mg/kg daily

24
Q

What is the standard dose and regimen for Infliximab in active Crohn’s disease?

A

5mg/kg initially, then in week 2, 6 and 14 and then every 8 weeks

25
Q

What is the standard dose and regimen for Adalimumab in active Crohn’s disease?

A

80mg initially, then 40mg every 2 weeks. If necessary increase to 40mg once weekly

26
Q

Why is budesonide used if conventional corticosteroids are not tolerated?

A

There is less systemic absorption, minimising the side effects of corticosteroids

27
Q

What is hepatic encephalopathy?

A

Confusion or altered consciousness caused by nitrates crossing the blood-brain barrier. This is a result of a build up of ammonia due to impaired liver function

28
Q

What is the laxative of choice to treat hepatic encephalopathy and what is the dose?

A

Lactulose

30-50ml TDS

29
Q

What is the treatment aim when using laxatives to treat hepatic encephalopathy?

A

Aim for 2-3 soft stools a day

30
Q

What can be used in combination with laxatives to reduce the recurrence of hepatic encephalopathy?

What dose?

A

Rifaximin 550mg twice a day

31
Q

What should be prescribed when performing an ascitic drain and how much?

A

Albumin 20%

100ml should be used to replace every 2L of fluid drained

32
Q

What can be used to treat the symptoms of alcohol withdrawal?

What determines the dose?

A

Chlordiazepoxide

The dose should be determined by a patient’s CIWA score

33
Q

Monitoring for thiopurines? (2)

A

Full blood count every week for first 4 weeks, then every 3 months

LFTs

34
Q

Side effects of glucocorticoids? (6)

A 
High blood sugars
Osteoporosis
Peptic ulcers
Immunosuppression
Adrenal suppression
Psychiatric reactions (insomnia, behavioural disturbances,)
35
Q

Side effects of mineralocorticoids? (5)

A 
Hypertension
Hypernatraemia
Water retention
Hypocalcaemia
Hypokalaemia
36
Q

What medications may you see prescribed alongside glucocorticoids? (2)

A

Colecalciferol+calcium

PPI (omeprazole, lansoprazole etc.)

37
Q

Monitoring for methotrexate?

A

Full blood count and kidney and liver function tests every 1-2 weeks until stabilised, then every 2-3 months

38
Q

How would you treat suspected or established Wernicke’s encephalopathy?

A

IV Pabrinex (vitamin B1) 2-3 pairs three times a day for 3-5 days, then 1 pair a day for 3-5 days

39
Q

What would you use to prevent Wernicke’s encephalopathy in alcoholic liver disease?

A

Pabrinex (vitamin B1) 1 pair daily for 5-7 days

40
Q

What should oral follow up should be used after a patient is treated with Pabrinex?

A

Thiamine, 50mg four times a day

41
Q

What is the dose and treatment regime for alcohol withdrawal symptoms in moderate dependence?

A

10-30mg chlordiazepoxide four times a day, reducing over 5-7 days (titration depends on local guidelines)

42
Q

What is the dose and treatment regime for alcohol withdrawal symptoms in severe dependence?

What is the maximum dose?

A

10-50mg chlordiazepoxide four times a day PLUS 10-40mg when required for first two days, reduce dose gradually over 7-10 days

Max 250mg a day

43
Q

First line treatment for H.pylori?

A

7 day treatment

PPI twice a day (omeprazole 20-40mg, lansoprazole 30mg etc)
Amoxicillin 1g three times a day
Clarithromycin 500mg/metronidazole 400mg twice a day

If penicillin allergic metronidazole 400mg twice a day instead of amoxicillin

Pharmacy Pre-Reg (8 decks)

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