IBD 1 - Ulcerative Colitis Flashcards
What are the main features of Crohn’s Disease? (4)
Involves distal ileum, proximal colon.
Can affect the entire digestive tract.
Inflammation can go through entire bowel wall thickness.
Thickening of the bowel wall
What are the main features of Ulcerative Colitis? (4)
Only the colon is affected.
Diffuse inflammation
Affects the colonic mucosa.
Cobblestoning structure
What are the s/s of IBD? (7)
Abdominal pain/cramping
Diarrhoea (+/- blood/mucus)
Urgency
Fever
Fatigue
Weight/Appetite loss
Mouth sores
What are the extra-intestinal manifestations of IBD? (6)
Skin, eye, joint and liver inflammation:
- Ankylosing Spondylitis (spine/hip joint)
- Arthritis
- Erythema Nodosum (skin flushing/shin tenderness)
- Pyoderma gangrenosum
- Uveitis (eye inflammation)
- Aphthous ulcers (painful open ulcers)
What are the potential complications of both CD + UC? (7)
High risk of colon cancer
Malnutrition
Anaemia
Risks associated with medication: Certain cancers, HPT, OP.
Blood clots
Primary sclerosing cholangitis
What are the potential complications of UC? (2)
Perforated colon
Toxic Megacolon
What are the potential complications of CD? (3)
Bowel wall Narrowing: Obstruction/Fistulas
Ulcers
Anal Fissures
What are the risk factors of IBD? (5)
Age
Family Hx
Infection
Smoking
Medication
What are the causes of IBD? (3)
Genetics
Environmental
Autoimmune
What investigations are carried out to diagnose IBD? (6)
Examination and Hx taking
Colonoscopy/sigmoidoscopy (Biopsy)
Stool cultures
Abdominal X-ray
Blood Tests (Anaemia/Inflammation)
Endoscopy
What are the differential diagnosis of IBD? (8)
Colorectal cancer
Other forms of IBD/colitis
Infection
Diverticular disease
IBS
Appendicitis
Ectopic pregnancy
PID.
When would steroids be used for IBD tx? (2)
Inducing remission.
Unsuitable for maintenance due to s/e.
What are the early effects of steroids? (5)
Acne
Oedema
Sleep + mood disturbances
Dyspepsia
Impaired glucose tolerance
What are the delayed effects of steroids? (5)
Cataracts
OP + Osteonecrosis
Myopathy
Infection susceptibility
Moon face
What are the glucocorticoid s/e of corticosteroids? (5)
Diabetes
OP
Myopathy (muscle wasting)
Peptic ulcers and perforation
Psychiatric reactions
What are the mineralcorticoid s/e of CS? (5)
HPT
Na retention
H2O retention
K loss
Ca loss
What hormones does the adrenal cortex secrete? (2)
Hydrocortisone (cortisol) which has glucocorticoid activity and weak mineralcorticoid activity.
Mineralcorticoid aldosterone.
Explain the effect of prolonged therapy with corticosteroids. (1)
Adrenal atrophy develops and can persist for years after stopping.
Explain the effect of acute withdrawal of prolonged therapy of corticosteroids. (1)
Can lead to acute adrenal insufficiency, hypotension or death.
How would you compensate for a diminished adrenocorticoid response caused by prolonged CS treatment, intercurrent illness, trauma or surgery? (2)
Temporarily increase CS dose OR
If already stopped, temporarily reintroduce CS treatment.
Explain how to avoid a fall in BP during anaesthesia. (1)
Anaesthetics should be informed whether a patient is or has been taking a CS.
What should every patient have if they are on long term CS treatment? (1)
Steroid card which contains warnings such as infections, chicken pox, measles and psychiatric reactions.
When would you consider a gradual withdrawal of corticosteroids? (5)
Received > 40mg of prednisone or equivalent for > 1 week.
Given repeated doses in the evening.
Received > 3 weeks tx.
Recently received repeated courses.
Taken a short course within 1 year of stopping long term therapy.
Explain why there’s a higher risk of patients of developing OP in IBD. (4)
Due to CS use also:
Lower BMI
Reduced physical activity
Disease activity
Explain the management of OP in IBD. (6)
Disease control
Good nutrition
Avoid steroids use
Lowest effective dose or steroids for shortest time possible.
Aza/6MP use at early stage.
Biological therapy or surgery should be considered if patient is unable to maintain a steroid free remission.
When would you consider bisphosphonates in OP management for IBD? (3)
When steroids for all > 65 yrs.
If < 65 but need steroids for > 3 months
Steroids stopped unless indicated.
Explain the process of inducing remission for acute severe IBD. (2)
- IV CCS: Ciclosporin/biologic (Infliximab)
- Can’t tolerate CCS/CI/decline - Add IV ciclosporin to IV CCS:
- No improvement with 72 hrs.
- Symptoms worsening
- OR consider a biologic (Infliximab)
What do you need to consider for inducing remission for acute severe disease? (4)
Need for surgery
Supportive therapy (fluids)
Stop harmful drugs (NSAIDs, Anticholinergics, Opioids)
VTE risk assessment (high risk VTE, prescribe LMWH)
What are the main features of ciclosporin? (3)
Used to induce or maintain remission
Brand Rx
Requires careful monitoring.
What are the common interactions of ciclosporin? (6)
Amiodarone
Atorvastatin
Carbamazepine
Clarithromycin
Dabigatran
Diclofenac
What are the monitoring requirements for Ciclosporin? (6)
Toxicity
Check serum cholesterol before starting
BP
Renal function
Liver function
Serum K, Mg
Drug levels
What are the main differences between CD + UC? (7)
CD:
- Disease distribution = Throughout the GIT.
- Rectal Involvement = Occassionally
- Type of Inflammation = Patchy, Transmural
- Diarrhoea = mild-severe
- Pain = Colicky (can mimic appendicitis)
- Extraintestinal symptoms = Yes
- Smokers = Higher rate
Ulcerative Colitis:
- Disease distribution: In the colon
- Rectal involvement: Usually
- Type of inflammation: Continuous, mucosal.
- Diarrhoea: Mild- very severe
- Pain: Lower abdominal discomfort
- Extra-intestinal symptoms: Yes
- Smokers: Lower rates
What are the treatment aims of IBD? (2)
Heal the inflammation and in turn reduce symptoms during a flare-up i.e. induce remission.
OR
Prevent flare up from happening.
What is the difference between mild, moderate and severe IBD based on Truelove and Witt’s severe index? (6)
Mild:
- Bowel movement (no. Per day) = < 4
- Blood in stool = no > small amounts of blood.
- Pyrexia (temp > 37.8) = No
- Pulse rate > 90bpm = No
- Anaemia (<10g/100ml) = No
- ESR (mom/hr) = <=30
Moderate:
- Bowel movement (no. Per day) = 4-6
- Blood in stool = mild to severe
- Pyrexia (temp > 37.8) = No
- Pulse rate > 90bpm = No
- Anaemia (<10g/100ml) = No
- ESR (mom/hr) = <=30
Severe:
- Bowel movement (no. Per day) = > 6 (+1 of the features of systemic upset)
- Blood in stool = visible blood.
- Pyrexia (temp > 37.8) = Yes
- Pulse rate > 90bpm = Yes
- Anaemia (<10g/100ml) = Yes
- ESR (mom/hr) = > 30
Explain the process of determining the treatment regimen for UC. (4)
Depends on location:
- Distal disease (proctitis, left sided below the splenic flexures) = Topical tx
- Extensive (pancolitis, beyond splenic flexures) = systemic
- Flare ups
- Maintenance of remission.
Explain the management of mild to moderate proctitis. (4)
Topical aminosalicylates alone
Consider adding oral aminosalicylates to topical agent
Consider a time-limited course of topical or oral CS.
Can consider oral aminosalicylate alone.
Explain the management process of mild to moderate proctosigmoiditis and left sided. (4)
1st line: topical aminosalicylates
High dose of oral aminosalicylates OR
Switch to high dose oral aminosalicylates and a time limited course of topical CCS .
If unable to tolerate aminosalicylates, consider time limited topical or oral steroids.
Explain the management of inducing remission of UC in mild to moderate disease. (3)
- Aminosalicylates:
- Topical (proctitis, proctosigmoiditis and left sided disease) or oral if topical is declined:- If no remission is achieved within 4 weeks, add in a high dose aminosalicylate.
- Topical + oral (extensive)
- If no remission is achieved within 4 weeks, add in a high dose aminosalicylate.
- Steroids:
- Prednisolone, Budesonide (Cortiment), Beclometasone (Clipper)
- Topical or oral
- If aminosalicylates aren’t tolerated.
- Or if there’s no improvement after 4 weeks.
- Or 1st line in moderate to severe disease. - Immunomodulators, Biologics, Combination of both, other licensed biologics.
What are the Rx safety of aminosalicylates? (4)
- Correct brand Rx
- C/i = salicylate allergy
- S/e - headaches, indigestion, nausea, water diarrhoea, mild allergic reactions. Rare = blood dysphasia’s, renal impairment
- Monitoring:
- Renal function, initially at 3 months and then annually.
- Counselling around blood dyspraxia’s.
What are the Rx safety of steroids? (3)
Correct dosing:
- Prednisolone:
- 30-40mg daily for 1-2 weeks then reduce by 5mg every 5-7 days until stop.
- Budesonide: Cortiment
- 9mg OD (morning)
- Up to 8 weeks.
- Beclometasone (Clipper)
- 5mg OD (morning)
- Up to 4 weeks.
Explain the process of maintaining remission for mild to moderate proctitis and proctosigmoiditis. (1)
Topical +/or oral aminosalicylates (daily or intermittent)
Explain the process of maintaining remission for mild to moderate left sided and extensive IBD. (1)
Low dose oral aminosalicylates.
Explain the process of maintaining remission for all extents of disease. (4)
Consider oral azathioprine or mercaptopurine to maintain remission:
- After 2 or more exacerbations in 12 months requiring tx with systemic CCS.
- OR if remission isn’t maintained by aminosalicylates.
- OR after a single episode of acute severe UC.
Explain the use of biologics in maintaining remission. (1)
If patients have moderate to severe disease and has not responded to conventional therapy, can’t tolerate it or it’s contraindicated.
Explain the use of JKI in maintaining remission. (1)
Moderate to severe disease and all other tx options have not been tolerated or failed treatment.
Give e.g. of JKI. (1)
Tofacitinib: Non-biologic, Potentn immunosuppressant.
What is the Rx safety of JKI? (3)
Not to be used in combination with biologics or immunomodulator drugs.
Increased frequency of VTE (use with caution in patients with additional risk factors for VTE, stop if VTE occurs.)
Not recommended for those > 65 yrs.
What pre-treatment screening is considered for JKI? (2)
TB
Viral Hepatitis
What is a common interaction with JKI? (1)
CYP3A4: Dose reduced in presence of CYP3A4 inhibitors.
Give e.g. of CYP3A4 inhibitors. (9)
Clarithromycin
Erythromycin
Itraconazole
Ketoconazole
Grapefruit Juice
Diltiazem
Verapamil
Goldenseal
Ritonavir
What are the monitoring requirements of JKI? (1)
Lipids 8 weeks after treatment started then periodically.
What are the common s/e of JKI? (4)
Headache
HPT
Diarrhoea
URTI
What does NICE guidelines state about new products? (5)
Estrasimod (Velsipity):
- Moderate to severe active UC
- > 16 yrs
- SIP receptor modulator
- Oral,
- OD.
