IBD Flashcards
IBD S/Sx
*Blood in stool
Diarrhea
Abdominal pain/cramps
Weight loss
Fatigue
Change in QoL
IBD Diagnosis
*Monitor Labs (ESR, CRP)
*Stool Studies (Lactoferrin, Calprotectin, Leukocytes)
Monitor symptoms
Colonoscopy
CT/MRIs
Types of UC
a. Proctitis: Only rectum
b. Left sided/Distal Colitis: involvement up to splenic flexure
c. Extensive/Pancolitis: involves entire large intestine
UC characteristics
- Confined to rectum + colon
- Continuous inflammation
- Progressive disease
- NO perianal involvement
UC complications
- Toxic megacolon
- Colon cancer
Chron’s characteristics
- Mouth to anus (entire GI tract)
- Most common in terminal ileum
- deep, patchy crypts
- “cobblestone appearance”
- Inc perianal involvement
Chron’s complications
- Malnutrition/vitamin deficiency (SI involved)
- Strictures
- Fistulas/fissures (perianal involvement)
5-aminosalicylates - Drugs
Sulfasalazine
*Mesalamine
Olsalazine
Basalazide
Mesalamine preps
- Rowasa: enema, delivers to the rectum and distal colon
- Canasa: suppository, delivers to rectum ONLY
- Pentasa: oral, delivers 5-ASA from rectum to jejunum (largest range of any rx)
Which disease are 5-ASA preferred?
UC
Immunomodulators - Drugs
*Azathioprine
6 - Mercaptopurine
Methotrexate
Cyclosporine
Benefits of combining Azathioprine with steroids/biologics?
a. Delayed effect (~3 months)
b. Steroid sparing (avoids long-term steroid therapy)
c. Inc efficacy of biologics due to dec antibody formation
Monitoring parameters on Azathioprine
a. CBC every 3 months
b. LFT/pancreatic enzymes
Azathioprine BBW
Lymphoma (inc. risk when combo with biologics)
Antibiotics - Drugs
Metronidazole
Ciprofloxacin
3rd gen cephalosporins
Which disease are ABX more commonly used?
Chron’s: perianal involvement (fistula/fissures)
- used short term to aid in closure
- cover gram(-) / anaerobes
Corticosteroids - Drugs
Prednisone
Methylprednisolone
Hydrocortisone
Budesonide
Budesonide formulations
a. Entocort: Chron’s (reaches terminal ileum)
b. Uceris: UC (only colon)
Benefits of Budesonide in IBD
- 15x potency vs Prednisone
- Poor systemic absorption = decreased ADEs
- do NOT combo with other steroids
- 8 week course of therapy
Biologics - Types
Anti-TNFs
Selective adhesion molecule (integrin) inhibitor
IL inhibitors
Anti-TNF - Drugs
Infliximab (IV)
Adalimumab (SQ)
Certolizumab (SQ)
Golimumab (SQ)
Response rate of Anti-TNFs in IBD patients?
~40%
- Infliximab #1 efficacy
- Adalimumab most convenient (monthly SQ inj.)
Anti-TNF BBWs
1.) Infections (TB, invasive fungal, bacterial, viral, opportunistic)
- require PPD, CXR, HBV/HCV/HIV testing
2.) Malignancy (lymphoma, inc. when combo with AZA)
Selective adhesion molecule (integrin) inhibitor - Drugs
Natalizumab (IV)
Vedolizumab (IV)
Which integrin inhibitor is preferred?
Vedolizumab (a4b7) - only targets T-cells in GI tract
Natalizumab BBW
PML (CNS infection)
IL Inhibitors - Drugs
IL-12, 23: Ustekinumab (IV, then SQ)
IL-23: Risankizumab (IV, then SQ)
NOT BIOLOGICS, but act like it - Types
JAK inhibitors
Sphingosine 1-Phosphate (S1P) Receptor Modulator
JAK inhibitors BBWs
- Cancer
- MACE
- Thrombosis
- Infections
- Death
When does FDA approve use of JAK inhibitors in IBD patients?
Patients who have failed 1 or more Anti-TNFs
General Biologics ADEs
IV: infusion reactions
a.) Acute: HA, fever, pruritis, nausea
- Premedicate with APAP, Benadryl, IV Steroids
b.) Chronic: flu-like symptoms
- Premedicate with APAP, short-term steroids
SQ: injection site reactions
Mild/Mod Active Crohn’s Diagnosis
- PO without fever, abdomen pain, intestine obstruct
- Weight loss < 10%
Mild/Mod Active Crohn’s Treatment
PO Budesonide (Entocort) x8 weeks
Mod/Severe Active Crohn’s Diagnosis
- Fever >38 C
- Weight loss > 10%
- Abdomen pain
- N/V
- Significant anemia
- Failed Mild therapy
Mod/Severe Active Crohn’s Treatment
a. PO Prednisone 40-60 mg
b. Anti-TNF (Inflix/Adalim)
+/- AZA (for either)
Severe/Fulminant Crohn’s Diagnosis
- High fever >39 C
- N/V with obstruction
- Cachexia (muscle wasting)
- Abscess
- Persistent symptoms despite systemic steroid/biologic
Severe/Fulminant Chron’s Treatment
a. IV MEPN/Hydrocortisone
b. IV Infliximab (after 6 weeks steroid)
c. *Surgery
Maintenance Therapy for Crohn’s (Remission)
a. AZA if steroid induced remission
b. Biologic +/- AZA if biologic induced remission
Perianal disease treatment
*ABX
Consider:
- Infliximab for closure
- Surgery if needed
Mild Active UC Diagnosis
- <4 stools
- Intermittent blood
- Occasional urgency
- Normal Hgb/ESR
- Elevated CRP/FC
Mild Active UC Treatment for Distal/Left Sided
a. Topical 5-ASA
b. Oral 5-ASA
*If 5-ASA failure:
a. PO Budesonide (Uceris) x8 weeks
Mild Active UC Treatment for Extensive Colitis
PO 5-ASA +/- Budesonide
Mod/Severe Active UC Diagnosis
- > 6 stools
- Frequent blood
- Often urgency
- <75% normal Hgb
- Elevated ESR/CRP/FC
Mod/Severe Active UC Treatment
a. PO Budesonide x8 weeks
b. Prednisone 40-60mg
c. Biologic
+/- AZA (for all)
Fulminant Active UC Diagnosis
- > 10 stools
- Continuous Blood
- Continuous Urgency
- Transfusion req (Hgb<8)
- Elevated ESR/CRP/FC
Fulminant Active UC Treatment
a. IV MEPN/Hydrocortisone
b. IV Infliximab
c. IV Cyclosporine
*Surgery (colectomy) will cure UC
Maintenance Therapy for Mild UC (Remission)
Topical or Oral 5-ASA
Maintenance Therapy for Mod-Severe-Fulminant UC (Remission)
a. AZA if steroid induced remission
b. Biologic +/- AZA if biologic induced remission
c. AZA or Vedolizumab if Cyclosporine induced remission
