IBD Flashcards
IBD
- Inflammatory bowel disease, that is chronic inflammatory disease of the GI tract
- Results in edema, ulceration, and tissue destruction
- Treatment requires flare therapy as well as maintenance therapy that prevents flare reoccurrence
IBD s/s
Diarrhea, blood in stool, abdominal pain, cramping, weight loss, fatigue, change in daily activities
Diagnosis of IBD
- Non invasive lab tests (ESR, CRP which are non specific markers of inflammation in the body)
- Stool studies (look for leukocytes in the stool)
- Endoscopy-colonoscopy (can look at entire colon and ileum, very invasive)
- CT/MRI (see if there is penetration of the disease into neighboring organs
IBD disease location (UC)
- Confined to the rectum (proctitis)
- Inflammation up rectum, sigmoid colon, descending colon and stop at splenic flexure (left sided colitis or distal)
- Inflammation past splenic flexure (extensive disease or pan colitis)
UC
- superficial inflammation
- confined to mucosa (continuous)
- anal involvement is not common
- patients at risk for megacolon or colon cancer
- Colectomy: removal of colon (cure)
IBD disease location (CD)
- Anywhere from mouth to anus
- Most common is terminal ileum (2/3 of patients)
- Perianal involvement is common
CD
- deep
- can go through all layers of intestinal wall
- patchy inflammation, cobblestone appearance
CD complications
- Malnutrition
- vitamin deficiencies
- strictures
- fistulas
- no cure
5-ASA
- Mesalamine
- Sulfasalazine
- Balsalazide
- Olsalazine
Immunomodulators
- Azathioprine
- 6-mercap
- Methotrexate
- Cyclosporine
- Tacrolimus
Antibiotics
- Metronidazole
- Ciprofloxacin or 3GC
Corticosteroids
- Prednisone
- Methylprednisolone
- Budesonide
- Hydrocortisone
Biologics
- Infliximab (UC/CD)
- Adalimumab (UC/CD)
- Certolizumab (CD)
- Golimumab (UD)
- Natalizumab (CD)
- Vedolizumab (UC/CD)
- Ustekinumab (UC/CD)
- Tofacitinib (UC)
5-ASA
- act topically to reduce inflammation in GI tract
- have to get to intestinal sire to work, have to modify drug delivery to get to site.
Sulfasalazine
- Sulfa is carrier
- Mesalamine is active component
- Sulfa is responsible for ADR: GI, rash, photosensitivity, blood dycrasias
Olsalazine
- 2 ASA molecules linked together and cleaved apart by gut bacteria in colon
- better tolerated than sulfasal but high diarrhea rate
Balsalazide
- Sulfasalazine without sulfa
- lots of drug to take
Mesalamine products
- not used in CD
- supp can only penetrate rectum
- enema can penetrate all the way to splenic flexure
- PO products will release somewhere in small or large intestine
Immunomodulators
maintain therapy remission
Azathioprine
-UC or CD (usually used in combo b/c takes a while to go into effect)
Methotrexate
- IM or SQ
- CD only
- CDC at least every 3 months
- LFTs and pancreatic enzymes
- Lymphomas (AZA alone or in combo with Infliximab)
Corticosteroids
- work quickly and dec inflammation
- no role in maintenance therapy
- topical hydrocortisone (enema, supp, or foam)
- PO pred
- IV hydro or methylpred
Budesonide
- more local, less systemic SE
- enteric coated capsule
- Entocort
- Uceris
Abx
- best for perianal (fistulas, fissures)
- CD only
Biologics
- Induce and maintain remission
- Anti-TNF (I, A, C, G)
- Selective adhesion (integrin) inhibitors (N, V)
- JAK inhibitor (T)
- IL inhibitors (U)
Biologic ADR
- IV: acute; HA, dizziness, nausea, flushing, fever, chest pain, cough, dyspnea, pruritis (pre medicate with Tylenol or antihistamine to dec effects)
- delayed: myalgias, arthralgia, fever, rash, pruitis, urticaria, HA (flu-like symp)
- SQ: injection site pain
Infections (biologics)
- warning on all
- BBW for TNF inhibitors and JAK inhibitors
- acute TB
- fungal infections
- monitor for s/s of infection
- should not receive live vaccines if on biologic
BBW biologics
Malignancy (TNF and JAK inhibitors)
Natalizumab
- can cause progressive multifocal leukoencephalpy
- lethal infection of CNS (JC virus)
- must be monotherapy (w/o steroids or immunomodulators
- TOUCH safety program
- last line therapy
JAK inhibitor (T)
- inc risk of cancer, death, thrombosis, cardiovascular events
- BBW
- only allowed for patients who have not responded or cannot tolerate TNF inhibitors
CD mild-mod
- in the community
- no fever
- no abd pain
- no obstruction
- < 10 % weight loss
CD mod-severe
- failed mild-mod therapy
- fever
- > 10% weight loss
- abd pain
- N/V with obstructions
- anemia (dec Hgb)
CD severe-fulminant
- persistent symp despite steroids or biologics
- need hospital treatment
- high fevers
- persistent N/V
- obstructions
- not eating
- intestinal abssesses
- severe abd pain
Mild-mod active therapy (CD)
- 1st line: budesonide (Entocort) for 8 weeks
- Patients with CD should not use 5-ASA products unless they have colonic involvement only (sulfsal specifically)
Mod-severe active therapy (CD)
- Systemic steroids (PO prednisone)
- Biologics (start with TNF inhibitor - Infliximab) - try others if no relief within 2-4 weeks
- AZA (reduces immune response but takes 4 months to get full effect
- steroid sparing
- better response rate when added with biologic
- reduce antibody production to biologic therapies
Severe-fulminant active therapy (CD)
- May need surgery
- IV steroids
- Infliximab of steroids don’t work
Perianal disease - fistulas or fissures
- Abx
- surgery
- Infliximab
- Don’t use abx if patient doesn’t have fistulas
Maintenance therapy (CD)
- 1st line: 5-MP/AZA/MTX
- Budesonide - can be used for additional 3 months
- Biologics: Infliximab or whatever was used for active
- 5-ASA should not be used in CD
Mild UC
- < 4 stools/day
- intermittent blood in stool
- Hgb normal
- ESR normal
- CRP elevated
- FC >150
Mod-severe UC
- > 6 stools/day
- frequent blood in stool
- Hgb <75% of normal
- elevated ESR/CRP
- FC >150
Fulminant UC
- > 10 stools/day
- continuous blood in stool
- blood transfusions
- Hgb < 8
- Elevated ESR/CRP/FC
Mild distal active therapy (UC)
- 1st line: topical 5-ASA
- 2nd line: oral 5-ASA
- combo PO + PR
- if doesn’t work use budesonide (Uceris)
Mild extensive active therapy (UC)
PO 5-ASA +/- budesonide
Mild extensive maintenance therapy (UC)
PO 5-ASA
Mild distal maintenance therapy (UC)
Topical 5-ASA or PO 5-ASA
Mod-severe active therapy (UC)
- budesonide, prednisone, biologic +/- 6-MP/AZA
- cannot use Methotrexate
Mod-severe maintenance therapy (UC)
- use what induced remission
- steroid: use 6-MP/AZA
biologic: continue +/- AZA
Fulminant active therapy (UC)
- 1st line: IV steroids, IV Infliximab
- IV cyclosporine
- surgery (colectomy) - cure
Fulminant maintenance therapy (UC)
- Use what induced remission
- Steroids: 6-MP/AZA
- biologic: continue +/- AZA
- cyclosporine: 6-MP/AZA or vetalizumab
