IBD Flashcards
What is Inflammatory Bowel Disease?
- Chronic or recurring immune response and inflammation of the gastrointestinal tract
What are the two types of of IBD?
- Ulcerative Colitis [UC]
- Crohn’s Disease [CD]
What is Ulcerative Colitis?
- Inflammation limited to the rectum and colon [only in large intestines]
- Smoking protects it??
What is Crohn’s Disease?
- Inflammation of the GI tract that can affect any part from the mouth to the anus [has fistulas]
What is the treatment overview for IBD?
- induce and maintain remission
What are some of the non-pharmacoloic therapies of IBD?
- Nutrition Support: EN, PN [last line], Vitamins
- Surgery: Proctocolectomy cures UC [removing colon = removed disease]
What are some of the classes that are used in the treatment of IBD?
- ASAs
- Corticosteroids
- Immunomodulators
- Biologics
- Antimircrobials
What is are the ASA agents that are used in IBD?
- Sulfasalazine = Sulfpyridine + 5-ASA [mesalamine]
What is the MOA for Sulfasalzine in IBD?
Which is ACTIVE or INACTIVE?
- Cleaved by colon bacteria to release the sulfpyridine [absorbed] & 5-ASA [stays in lumen]
- Sulfpyridine is INACTIVE
- 5-ASA is ACTIVE [causing inflammation]
What is important to know about giving Mesalamine alone in IBD?
Indication? Dosage Forms?
- Rapidly and completely absorbed in intestine BUT not in colon
- Topical [enema: left-sided disease], Suppository [Proctitis], Oral
- Topical > Oral; can combo
What are some of the Adverse Drug Reactions for ASA agents?
- Sulfasalazine: N/V, Headache, rash, Hypersensitivity [SULFA]
- Mesalamine: N/V, Headache, increased bleeding [no antiplatelet/coags/NSAIDS], pH affects [PPIs/H2RAs/Antacids]
What are Cortcosteroids good for in IBD?
MOA? Main Use?
- MOA: anti-inflammatory
- Used for induction NOT maintenance
- Suppositories [Proctitis] & Enema [Left-sided disease]
What is the corticosteroid that is used?
- Budesonide
What is important to know about Budsonide for IBD?
- First pass metabolism [CYP3A inhibitor: ketoconazole, grapefruit = INCREASE exposure]
- PO and Foam
What are the Systemic Cortiosteroids that are used in IBD?
- Oral Prednisone & Prednisolone [IV methylprednisolone too]
- TAPER
What are some of the Adverse Drug Reaction for Systemic Corticosteroids in IBD?
Short Term or Long Term?
- Short Term: Hyperglycemia, Gastrits, Mood Swings, Increased BP
- Long Term: Cataracts, Obesity, Growth Failure, Osteoporosis
What are the Immunosuppresive agents that are used in IBD?
- Azathioprine [AZA]
- Mercaptopurine [6-MP]
- Cyclosporine
- Methotrexate
What are Azathioprine & Mercaptopurine good for in IBD?
Place in treatment? Other Info?
- Long Term treatment of UC & CD [for those that have faild 5-ASA & steriods] - good for Maintanence
- AZA becomes 6-MP [Prodrug]
What are some of the Adverse Drug Reactions for Azathioprine & Mercaptopurine in IBD?
- N/D/V, Bone Marrow Suppression, Hepatotoxicity, Fever, Rash
What are some Monitoring to know for Azathiopurine & Mercaptopurine in IBD?
- TMPT, CBC, LFTs
What is important to know about Cyclosporine in IBD?
Indication? Dosage Forms?
- NOT CD but good at Inducing remission in UC [not long term]
- NOT for those that fail AZA & 6-MP
- IV or PO
What are the Adverse Drug Reactions for Cyclosporine in IBD?
- Nephrotoxity, Neurotoxicity, HTN, GI upset
- Drug interactions: CYP3A & PGP
What are some of the Monitoring to do for Cyclosporine in IBD?
- BP [bc of HTN], BUN/Scr, LFTs
What is important to know about Methotrexate in IBD?
Indication? Dosage Forms?
- Used in CD for induction
- SubQ or IM
What are the Adverse Drug Reactions for Methotrexate in IBD?
Just like in RA?
- Bone Marrow Suppression [add folic acid], N/V/D, cirrhosis, rash, TERATOGENIC
What are some Monitoring to do for Methotrexate in IBD?
Just like in RA?
- CXR [chest xray], CBC, SCr, LFTs
What are the biologics that are used in IBD?
Three Categories?
- TNF-a Antagonist [Infliximab, Adalimumab, Golimumab, Cartolizumab]
- Others [Natalizumab, Vedolizumab, Ustkinumab, Risankizumab, Mirikizumab]
- Small Molecules [Tofacitnib, Upadacitinib, Ozanmiod, Estrasimod]
What are some of the general Adverse Drug Reactions for the TNF-a Inhibitors in IBD?
Just like in RA?
- Increased risk of infection [PPD, CXR, Hep B/C; Up to date vaccines, NO live vaccines]
- SubQ or IV
- Risk of Lymphoma, CHF
What are some of the general Monitoring for TNF-a Inhibitors in IBD?
Monitoring for basically ALL Biologics!
Just like in RA?
-
CXR, PPD, Infections, UA, CBC, SCr, LFT
Hep B & C
What is important to know about Infliximab [Remicade] in IBD?
MOA? Indication? Place in Treatment?
- UC & CD for induction and maintenance
- IV
- Forming Antibodies [decrease response, D/C]
TNF a- Antagonist
What is some extra Monitoring for Infliximab in IBD?
- Infections, Vitals, Infusion Reactions, TDM
What is Adalimumab [Humira] good for in IBD?
Types of IBD? Dosage?
- UC & CD for inducation and maintenance of Mod-Severe UC/CD
- Those that Failed Inflixumab
- SubQ
- Forming Antibodies
TNF-a Antagonist
What is important to know about Golimumab [Simponi] in IBD?
- ONLY in UC for induction and maintenance
- SubQ
- Forming Antibodies
What is important to know about Certolizumab [Cimzia] in IBD?
- ONLY in CD for induction and maintenance
- SubQ
- Forming Antibodies
What is Natalizumab [Tysabri] good for in IBD?
MOA? Type of IBD? Dosing?
- MOA: Anti-a-subunit [decrease inflammation]
- ONLY in CD for induction and maintaining remission, those that fail TNF
- IV
What are the Adverse Drug Reactions for Natalizumab in IBD?
One MAIN one
- PML [test for JC virus]
- Similar to other biologics
What is Vedolizumab [Entyvio] good for in IBD?
MOA? Type of IBD? Dosage?
- Anti-a4b7 antinbody
- UC & CD for induction and maintanence
- IV
- ADRs like biologics
“Other” Biologics
What is important to know about Ustekinumab [Stelara] in IBD?
MOA? Indication? Place in treatment?
- IL-12 and IL-23 antagonist [IL is important for inflammation]
- UC & CD for inducation [IV] and maintenance [SubQ]
What is important to know about Risankizumab-rzaa [Skyrizi] in IBD?
MOA? Indication? Dosage Forms?
- IL-23 antagonist
- CD those that failed biologics including Ustekizumab for Induction [IV] and maintenance [SubQ]
What are the Adverse Drug Reactions for Risankizumab in IBD?
- Headache, Nasopharyngitis, Abdominal Pain, Anemia, Nausea
- Forming Antibodies [PPD, Vaccines?, avoid live vaccines]
What is some of the monitoring for Risankizumab in IBD?
Typical ones?
- CXR, PPD, Hep B/C, Lipids, LFTs
What is important to know about Mirilizumab-mrkz [Omvoh] in IBD?
MOA? Indication? Dosage Forms?
- IL-23p19 antagonist
- UC for those that failed biologics or JAK; induction [IV] and maintenance [SubQ]
What are the Adverse Drug Reactions for Miriklizumab in IBD?
- Headache, Rash, injection site reactions
- Forming Antibodies [PPD, Vaccine?, Avoid live vaccine]
What are some monitoring to do for Mirikizumab in IBD?
- CXR, PPD, Hep B/C, Lipids, LFTs
What is the TDM of Biologics?
Think Table?
- Sub-therapeutic & Detect: Change drug same class
- Sub-theraputic & Undetect: increase dose
- Therapeutic & Detect: Change drug out of class
- Theraputic & undetect: Change drug out of class
What is important to know abourt Tofacitinib [Xeljanz] in IBD?
MOA? Indication? Dosage Forms?
- ORAL JAK inhibitor [enzymes involved in immune signaling]
- ONLY of UC for those that failed TNF and Biologics
- NOT used with Immunosuppressants or biologics [combo]
What are the Adverse Drug Reactions of Tofacitinib in IBD?
- Diarrhea, increased cholesterol, headahce, herpes, rash, increased infection [PPD, CXR, Hep B/C, Vaccine?, Avoid Live Vaccines]
- BLACK BOX WARNING: Cardiovascular issues
What are some monitoring for Tofacitnib for in IBD?
- CXR, PPD, Hep B/C, ANC, CBC, Lipids, LFTs, Infections
What is Upadacitinib [Rinvoq] good for in IBD?
MOA? Type of IBD? Dosage?
- ORAL JAK1 inhibitor [JAK is good for immune signaling]
- UC [8w] & CD [12w] for those that have fail TNF
What are the Adverse Drug reactions for Upadacitinib in IBD?
Basically the same as Tofacitinib, Black Box Warning?
- URT infection, Ance, Increased Cholesterol, Headache, Shingles
- BLACK BOX WARNING: Cardiovascular
- Increased infections risk [PPD, CXR, Hep B/C, Vaccine?, Avoid Live Vaccines]
Only changeD for Tofactinib & URT/Ance Infections for Upadacitinib
What are some of the Monitoring to do for Upadacitinib in IBD?
- CXR, PPD, Hep B/C, ANC/ALC, CBC, Lipids, LFTs Infections
Has ANC?? what other one does too?
What is Ozanimod [Zeposia] good for in IBD?
MOA? Type of IBD? Place in Treatment
- Oral S1P modulator that prevents lymphocyte mobilization in inflammatory sites
- ONLY for UC
- Induction and maintenance
New Small Molecules
What are some contraindications for Ozanimod in IBD?
- Cardio issues
- Sleep Apnea
- Taking MAO inhibitors
What are the Adverse Drug Reactions for Ozanimod in IBD?
- Increased Infection risk,PML [really with the other drugs in this class so maybe with this one too], Increased BP, Edema, Bradycardia
- Drug Interactions: MAO, CYP2C8 inhibitors and inducers
What are some of the monitoring for Ozanimod in IBD?
- CXR, PPD, Hep B/C, CBC, LFTs, Infections, BP, ECG
-imods have BP
What is important to know about Estrasimod [Velsipity] in IBD?
MOA? Indiction? Place in Treatment?
- Oral S1P modulator: prevents lymphocyte mobilization in inflammatory sites
- ONLY for UC for induction and maintenance [10/2023]
Same as Ozanimod
What are some Adverse Drug Reactions for Estrasimod in IBD?
Like Ozanimod?
- Increased infection risk, PML [with other drugs within the same class], Increased BP, Bradycardia, Edema
- Sleep Apnea?
Sleep Apnea is a contraindication?
What are some monitoring for Estrasimod in IBD?
- CXR, PPD, Hep B/C, CBC, LFTs, Infections, BP, ECG
-imods have BP
What are some Antimicrobials that are in IBD?
- Ciprofloxacin, metronidazole, Rifamycin
- Maybe used in CD with fistulas
- C. Diff
What dosage form to use for what UC issue in Mild-Moderate Active UC?
- left-sided = enema
- proctits = supp.
- extensive = systemic
What is some Oral and/or Topical medications to use for Mild-Moderate Active UC?
- ASA [Mesalamine > sulfasalazine]
- Extensive –> oral 5-ASA
- Left-sided –> Enema
- proctits –> Supp.
- Combo oral/topical is better
What should you do if 5-ASA is unresponsive in Mild-Moderate Active UC?
- Changing Formulation [increase dose, do Combo, change product]
What steroids might be used in Mild-Moderate Active UC?
- CR Budesonide [or pred] in oral or topical 5-ASA fails
- PO corticosteroid
- NOT for maintenance, only for remission
What is important to know about Moderate-Severe Active UC?
- 4-6 stools per day, +/- bloody stools
- NO methotrexate for induction or maintenance
- COMBO TNF, Vedolizumab, or Ustekinumab with Thiopurine or MTX [decrease antibodies
What are some treatment options for Moderate-Severe Active UC?
- 5-ASA for moderate NOT severe
- Systemic Corticosteroids [moderate use PO Budesonide]
- Consider TNF [those that failed ASA & Steroids]
What are some medication class that are used in Moderate-Severe Active UC?
- TNF Inhibitor, Anti-Integrin, IL12/IL23 inhibitors, JAK inhibitors, S1P inhibitor
What is important to know about Severe-Fulminant Active UC?
- 6-10 Bowel Movements, NPO?
- Parenteral Corticosteroids [Methylprednisolone or Hydrocortisone x3-7d]
- TNF [Infliximab] or Cyclosporine if failed IV steroids
What should you used for Maintenance of Remission in UC?
- Basically used what got you into remission [ASA, TNF, Azathioprine, or 6-MP]
- Failed ASA or Steroids = Azathioprine or 6-MP
What is important to knwo about 5-ASA and Sulfasalazine in Mild-Moderate Active CD?
- Sulfasalamine = slight effect
- 5-ASA = no effect
