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IBD Flashcards

1
Q

What is IBD?

A

A group of chronic diseases

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2
Q

What conditions come under IBD?

A

Crohn’s disease

Ulcerative colitis

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3
Q

What is Crohn’s disease?

A

Patchy transmural ulceration of all layers of the intestinal wall and can affect the whole of GIT mouth to anus

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4
Q

What is Ulcerative Colitis?

A

Confluent mucosal inflammation and ulceration of colon and rectum mucosa affecting mucosal and submucosal layers
Superficial inflammation

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5
Q

What are the implications of inflammation of gastric mucosa?

A

Relapsing and remitting

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6
Q

What are the implications of continuous inflammation?

A

Local destruction of GIT mainly bowel

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7
Q

What are the causes of IBD?

A

Genetic
Air pollution
Smoking
Infection
Medication
Diet
Gut microbes
Immunological
 Toxic response to luminal contents
 Specific microbial pathogen
 Abnormal luminal constituents
 Increased absorption of luminal macro molecules
 Enhanced immunologic response to normal constituents
 Autoimmune response
 To epithelial cell or mucus glycoproteins
 Molecular mimicry (cross-reactivity of intestinal microflora and epithelia)
 To immune cells

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8
Q

What are the signs and symptoms?

A 
Abdominal pain
Diarrhoea- watery, bloody, mucous
Tiredness
Fatigue
Urgency
Weight loss
Anaemia
Fever
Nausea
Vomiting
Abdominal bloating and distension
UC= more bleeding
CD= more obstruction 
Extra intestinal manifestations 
    	Swollen joints- arthritis
    	Eye problems- episcleritis, iritis, uveitis
   	Erythema nodosum- swollen fat under skin causing redness, bumps + lumps
   	Pyoderma gangrenosum- skin ulceration
   	Primary sclerosing cholangitis
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9
Q

What complications does CD cause?

A

STRICTURES
- narrowed bowel segments causing blockage, acute dilation, perforation
FISTULAS
- Abnormal channels lined with granulation tissue between intestine and skin or other parts of intestine or organs like the bladder

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10
Q

What variables are used in the CD activity index?

A 
Number of liquid or soft stools
Severity of Abd pain
General well being
Complications present
Fever
Is loperamide being used
Is there anaemia
Body weight
Is there an abdominal mass or not
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11
Q

What indicates the presence of severe active CD?

A 
Poor general health
Weight loss
Severe Abd pain
Fever 
Frequent diarrhoeal stools 3-4x daily 
New fistulae
Extra intestinal manifestations 
Score >300 
Harvey Bradshaw score >8-9
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12
Q

What diagnostic tests and investigations are used?

A 
Full history and detailed clinical exam
Full blood count
Inflammatory markers
U + E
Thyroid function test
Liver function test
Bone profile 
Stool culture to rule out c.difficile 
Coeliac screen 
Faecal calprotectin 
Abdominal imaging
Endoscopy + capsule endoscopy
Colonoscopy
Biopsies to differentiate between CD and UC
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13
Q

What index is used to assess UC and its variables?

A 
Truelove and wits severity index
Bowel movements
blood in stool
pyrexia
pulse rate
anaemia
erythrocyte sedimentation rate
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14
Q

What is monitored in the case of acute relapse or flare?

A 
Faecal calprotectin
Stool frequency
Blood or mucous in stool
Temp
C reactive protein
U + E
HR- tachycardia 
BP- hypotension
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15
Q

What are the management aims of IBD?

A 
Achieve remission
Maintain remission 
Improve quality of life 
Avoid surgery
Reduce long term steroid use 
Reduce risk of  colorectal cancer 
Reduce risk of other complications
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16
Q

What are the formulations used and where is the drug released in the bowel?

A 
Suppository = Rectum
Foam = Sigmoid colon
Enemas = Descending colon to distal parts of transverse colon
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17
Q

What do you need to consider when choosing pharmacological treatment?

A

Patient preference
Route of admin
Preferred formulation
Licensed indications

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18
Q

What are the treatments/managements used in IBD?

A 
Corticosteroids
Amino-salicylates
Immunodulating agents
Biologics
Antibiotics
Novel treatments
Surgical
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19
Q

What is the MOA of corticosteroids specifically prednisolone?

A 
Induce disease remission
Treats flares
Doesn’t prevent progression or complications
Reduce inflammation
Modulate immune system

PREDNISOLONE
Binds to cellular glucorticoid receptor
Inhibits inflammatory cells
Suppresses expression of inflammatory mediators

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20
Q

What corticosteroids are used in IBD?

A

Prednisolone- 40mg OD
Hydrocortisone IV for severe-acute in hospital 100mg QDS
Budesonide
Methylprednisolone

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21
Q

When are the indications of corticosteroids?

A

Mild
Moderate
Severe

22
Q

What are the ADRs of corticosteroids?

A 
GI
Fluid and electrolyte imbalance
Increased appetite
Hypertension
Blood sugar effect
Mood and behaviour change 
Risk of infection
Osteoporosis risk
23
Q

What card to corticosteroid users need to carry?

A

Steroid emergency card

24
Q

Why can corticosteroids not be stopped abruptly?

A

Risk of adrenal suppression

25
What is the MOA of Amino-salicylates?
Anti-inflammatory action throughout GIT Decrease prostaglandin in colon Inhibits production of pro-inflammatory cytokines Induce and maintain remission in mild-mod UC
26
What Amino-salicylates are used in IBD?
Sulfasalazine Mesalazine Balsalazide Olsalazine
27
What molecule are Amino-salicylates derived from and what makes the drugs differ?
5-ASA ``` Mesalazine= 5-ASA+ ph sensitive coating Balsalazide= 5-ASA + inert carrier molecule Olsalazine = 5-ASA + 5-ASA ```
28
What are the ADRs of Amino-salicylates?
``` Arthralgia Abd pain Diarrhoea Blood dyscrasias Dizziness ```
29
What monitoring is required with Amino-salicylates?
Renal function | Blood dyscrasias/full blood count
30
What counselling points should be given when on Amino-salicylates?
Report unexplained bleeding, bruising, purpura, sore throat, mouth ulcers, fever, malaise Administration advice Maintain same brand but if switched report symptoms
31
What is the MOA of Immunodulating agent thiopurines?
Induce and maintain remission Reduces GIT inflammation Suppresses immune response and inflammation Metabolites impact on adaptive, innate, and non-immune cells within inflamed intestine Steroid-sparing
32
What thiopurines are used?
azathioprine- pro drug which turns into mercaptopurine | mercaptopurine
33
What is the dose range for the thiopurines?
Azathioprine – 2 - 2.5mg/kg/day | Mercaptopurine – 1 - 1.5mg/kg/day
34
Describe the steps in mercaptopurine metabolism?
Mercaptopurine metabolised to thioguanine nucleotides (TGN) which is the active metabolite by thiopurine methyltransferase (TMPT) mercaptopurine to methylmercaptopurine (MeMP) MeMP not pharmacologically active= hepatotoxicity
35
What test needs to be conducted before using thiopurine and what do the results indicate?
TMPT levels before and after Low TMPT= reduced dose as there is risk of myelosuppression High TMPT= hepatotoxicity risk Full blood count before- then every week for first 4 weeks then every 3 months
36
What are the ADRs of Immunodulating agents?
``` Hypersensitivity= immediately withdraw Myelosuppression Neutropenia Thrombocytopenia GI- nausea, vom, diarrhoea Liver disorders ```
37
Describe the pharmacology of the Immunodulating agent methotrexate?
For maintenance in CD Alternative to azathioprine 1 x weekly Co prescribed with folic acid
38
Describe the pharmacology of the Immunodulating agent Ciclosporin?
IV Induces remission in severe acute UC Steroid alternative
39
Describe the pharmacology of the Immunodulating agent Tacrolimus?
Oral Induces remission in mild/mod UC Used if no response to other treatments
40
What is the MOA of biologics?
``` Monoclonal antibodies Bind to cytokine TNF alpha TNF-a is naturally occurring cytokine Mediates inflammatory responses Modulates immune system Central role in CD Inhibit inflammatory gut effect Mod/severe IBD No response to immunodulating agents ```
41
What biologics are used?
``` - MABS Infliximab Adalimumab Vedolizumab Ustekinumab ```
42
Describe the pharmacology of Infliximab?
First approved TNF blocker Murine and human AA sequence IV infusion Can cause flu like symptoms so pre-med is given Screening before treatment of TB, Hep B and C, HIV Risk of lymphoma Biosimilar available
43
Describe the pharmacology of Adalimumab?
Fully humanised SC injection Risk of infection reactivation and malignancy reactivating Screening before treatment of TB, Hep B and C, HIV Bio similar available
44
Describe the pharmacology of Vedolizumab?
Leukocyte adhesion inhibitor so inhibits leukocyte migration to parenchymal tissue in gut and reduces inflammation IV infusion Risk of reactivation of infections and malignancy
45
Describe the pharmacology of Ustekinumab?
Blocks IL-12 and 23 Inhibits inflammatory effects in gut Initial IV infusion then SC injection Risk of reactivation of infections and malignancy
46
What are the novel treatments?
Faecal microbiota transplant | Probiotics
47
Explain what a Faecal microbiota transplant involves?
Transfer of gut micro-organisms from health donor into intestinal tract
48
Describe the pharmacology of Probiotics?
New biologics Small molecules MOA= Inhibitors of RNA and intracellular cytokine pathway
49
What types of surgical treatments are used?
Radical surgery in UC | CD surgery
50
What complications require immediate surgery?
``` Intestinal blockage Bleeding Perforation Fistula Abscess Toxic megacolon ```
51
What are the types of elective IBD procedures?
``` Bowel resection Strictureplasty Colectomy Proctocolectomy with ileostomy Fistula treatment Abscess drainage ```
52
What is the role of a pharmacist in IBD?
Recommend therapy and treatment Ensure formulation is appropriate Advice on administration to patient and other HCP For corticosteroids  Ensure dose is appropriate  Ensure regimen is appropriate- the reduced regimen  Co prescribed with Ca and vit d to prevent osteoporosis  ADR monitoring For amino salicylates  Adjustment dose for flares/remission Counsel on side effects- blood dyscrasias Safe and appropriate biologics use Plan how to stop meds for patients in remission Rescue strategy if there is relapse Support adherence and health literacy Therapeutic drug monitoring Prescribing clinics- more specialist roles Input into IBD standards and NICE guidelines Use of biosimilars

THE PATIENT (8 decks)

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