IBD

Question 1

What is IBD?

Answer 1

chronic inflammatory condition of the GI tract
characterized by periods of remission and activity
main forms are UC and Crohn’s disease

Question 2

Ulcerative Colitis

Answer 2

continuous superficial (top layer) inflamm in the colon only
risk of GI cancer
extraintestinal manifestations

Question 3

Crohn’s disease

Answer 3

patchy inflammation
mouth to anus involvement
full thickness inflamm
fistulas and strictures

Question 4

Signs & symptoms of CD

Answer 4

abdominal pain
diarrhea
weight loss
fatigue
iron deficiency anemia
extraintestinal manifestations

Question 5

Signs & symptoms of UC

Answer 5

fecal urgency
tenesumus
hematochezia
abdominal pain
fever
iron deficiency anemua
extraintestinal manifestations

Question 6

Goals of IBD therapy

Answer 6

induce symptomatic remission
maintain steroid free remission
control inflamm
enhance QoL
prevent/treat complications of disease
avoid short and long term toxicity of therpay

Question 7

Crohn’s disease high risk factors for rapid progression to bowel damage and disability

Answer 7

early onset < 40yr
small bowel involvement
perianal disease
endoscopic severe lesions
prior surgical resection

Question 8

5-ASA drugs (balsalazide, mesalamine, sulfasalazine)

Answer 8

small to no benefit in CD
effective for inducing remission in UC in 2-8wk
once daily dosing effectcive

Question 9

Corticosteroids

Answer 9

indicated for: those failing 5-ASA, budesonide, OR mod severe disease
induction of remission, not a maintenance
poor side effect profile
can be used in combo with an anti-TNF to induce remission
doses > 60mg/d not effective
effective in 1-3 wk
anticipate steroid dependence in ˜25% of patients

Question 10

Adverse Effects of corticosteroids

Answer 10

infection
HTN
diabetes
osteonecrosis
osteoporosis
myopathy
cataracts
glaucoma
psychosis

Question 11

Thiopurines (mercaptopurine, azathiopurine)

Answer 11

indicated for: steroid dependence, part of combo therapy with biologics, post op prophylaxis(CD) and fistulas
TMPT testing advised
Onset of effect: 8-16wk
dosing:
mercaptopurine: 1-1.5mg/kg
azathiopurine: 2-2.5mg/kg

Question 12

Methotrexate

Answer 12

indicated for: CD and UC, steroid dependence, steroid refractory, part of combo therapy with biologics
onset of effect: 8-16wk
dosing: SC or IM - 25mg wk
PO - 7.5-15 mg weekly

Question 13

Anti-TNFs (infliximab, adalimumab, certolizumab pegol (CD), golimumab (UC)

Answer 13

indicated for: mod-severe disease, steroid dependence/refractory, refractory to immunomodulators
severe, IV steroid refractory UC, fistulizing CD, selected patients with early CD
onset: 2-6wk
side effects: CHF, hepatotox, cancer, infection, bone marrow supression, infusion rxns

Question 14

Anti-adhesion therapy (vedolizumab)

Answer 14

indicated for: active UC or CD despite steroids, immune modulators, or anti-TNF
onset: early as 2 wks late as 10
consider in combo with immune modulators

Question 15

Ustekinumab

Answer 15

Mab to IL-12 and IL-23

indicated for: mod - severe crohn’s disease

Question 16

Tofacitinib

Answer 16

oral drug
JAK inhibitor
mod to severe UC

Question 17

Thiopurine metabolites and poor response

Answer 17

Absent TGN and MMP = non-adherence –> education
low TGN low MMP = under dosing –> incr dose
low TGN high MMP = thiopurine resistance –> allopurinol
ther TGN and MMP = thiopurine refractory –> diff drug
high TGN high MMP = over dosing –> decr dose

Question 18

Treatment for loss of response to anti-TNFs

Answer 18

positive ADA –> change to another anti-TNF agent –> change to a non anti-TNF if persistent disease
therapeutic TNF conc –> active disease on exam? –> yes: change to different anti-TNF; no: investigate alternate etiologies
subtherapeutic TNF –> increase dose or switch agents

Question 19

Risk of infection in IBD

Answer 19

many infections preventable with routine immunization

screening for Tb and Hep B recommended prior to initiating therapy