IBD

Question 1

Risk Factors

Answer 1

-GENETICS
-Smoking protective in UC but can worsen CD
-Diet (sugar, fat, protein)
-Infectious
-Medications (NSAIDS, ABX, CONTRA)

Question 2

IBD Signs and Symptoms

Answer 2

CD
-weight loss
-fissures
-fistula
-ulcers

UC
-hematochezia
-tenesmus

Question 3

Crohn’s Disease - Treatment Decisions

Answer 3

Mild/Mod
-Sulfasalazine
-Steroids
-Budesonide
-Aza, 6-merc, mtx

Mod/Sev
-IV/PO steroids
-Bio (TNF, IL, integrin)
-Aza, 6-merc. mth
-JAK

Question 4

Fistulas

Answer 4

Drain abscess before tx

Medication
-Anti TNF or thiopurines or combo
*Infliximab preferred (ada, certo)
-ABX (metro, cipro, levo) for active infection and to decrease fistula drainage

Question 5

Ulcerative Colitis - Treatment Decisions

Answer 5

Mild/Mod
-5 ASA
-Budesonide
-CS

Mod/Sev
-5 ASA
-Budesonide
-CS
-THIO/MTX
-TNF/integrin/IL
-JAK
-S1P

Question 6

Treatment Guidelines – Maintenance (UC)
Mild/Moderate

Answer 6

Mild/Mod: oral/top 5 ASA

Mod/Sev: THIO/BIO/MTX/JAK/S1P

Question 7

Goals of Therapy

Answer 7

• Treat to Target
• Resolution of symptoms
• Mucosal healing
• Endoscopic remission
• Prevent complications
• Improve quality of life
• Minimize risk for CRC
• Prevent or manage extraintestinal manifestations

Question 8

Sulfasalazine
-ASA

Answer 8

colonic involvement

AE:
-NV
-HA
-HS (rash)
-Anemia
-Pneumonitis
-Hepatoxicity
-Nephritis
-Thrombocytopenia
-Male infertility

MON:
-Folate
-CBC
-LFT
-BUN/Scr

Folic acid supplementation

CI: SULFA allergy

Question 9

Mesalamine, olsalazine, balsalazide
-ASA

Answer 9

colonic involvement

AE:
-Diarrhea
-Abd pain
-HA
-Nausea

MON: GI upset

Fluids
-Food: olsalazine, lialda
-WO: asacol, apriso

Question 10

CS

Answer 10

Induction only (not main)

• Impaired glucose
• Dyslipidemia
• Hypertension
• Osteoporosis
• Edema
• Infection
• Acne
• Myopathy
• Psychosis

MON: BG, BP, inf, elev, lipids, bone density

Question 11

Methotrexate

Answer 11

• Renal impairment (BBW)
• Myelosuppression
• Pancreatitis
• Hepatotoxicity
• Pneumonitis
• Infection
• Malignancy
• Alopecia
• Male infertility

MON: CBC, LFT, pregnancy test, SCR, Folate supplementation

DDI: NSAID, pheny, tetra, sulf

Question 12

Azathioprine, 6-Mercaptopurine

Answer 12

• Bone marrow suppression
• Pancreatitis
• Lymphoma
• Hepatotoxicity
• Nausea
• Non-melanoma skin cancer

MON: LFT, CBC, TPMT

DDI: Allopurinol

Question 13

Cyclosporine

Answer 13

Adverse effects
* Nephrotoxicity
* Neurotoxicity

Monitoring
* BUN/Scr
* Signs of neurotoxicity

FOR
* Acute severe UC to avoid colectomy
* Failing corticosteroids
* Short term inpatient use only

Question 14

Infliximab, Adalimumab, Golimumab, Certolizumab
-ANTI TNF

Answer 14

IND and MAIN of IBD

CI:
-Active infection
-Latent TB (untreated)
-HF
-Recent malignancy
-Optic neuritis
-Demyelinating disorder

AE:
-BBW Infection
-BBW Malignancy
-Infusion related
-Vasculitis
-BMS
-Hepatoxicity
-MS, lupus

MON:
-TB, CBC, LFT, BP, HR

Avoid live vaccines

Question 15

Natalizumab
-Anti-Integrin Therapy

Answer 15

BBW: PML
-progressive multifocal leukoencephalopathy
-sx: one side weak, clumsy, vision, cognitive

ONLY THROUGH REMS

CI: PML, hepatic, combo with other IS/TNF

AE:
-HA, fatigue
-Arthalgia, rash
-Infusion
-Depression
-Infection
-Hepatoxicity
-Thrombocytopenia

Question 16

Vedolizumab
-Anti-Integrin Therapy

Answer 16

• Nausea
• Headache
• Arthralgias
• Infection
• Infusion reactions
• Rash
• Pruritis
• Immunogenicity
• Nasopharyngitis
• Injection site reactions (SQ)

MON: CBC, LFT, BP, HR, mental status

Question 17

Ustekinumab, Risankizumab, Mirikizumab
-Anti IL 12/23

Answer 17

-Infections
-TB
-HS
-Malignancy
*warnings

AE:
* Nasopharyngitis
* Injection site erythema
* Vulvovaginal candidiasis
* Upper Respiratory Infections
* Pruritis, arthalgias
* UTI
* Sinusitis, HA, fever, fatigue, NV
* Hepatotoxicity

MON: TB, LFT
-no live vaccines

Question 18

JAK
-Tofacitinib (UC), Upadacitinib

Answer 18

BBW
-Infections
-Thrombosis
-MACE
-Malignancy
-Mortality

MON: TB, CBC, LFT, lipids
-avoid live vaccines

DDI: 3A4 and 2C19

Question 19

S1P
-Ozanimod, Etrasimod

Answer 19

CI:
*last 6 mo:
* Myocardial infarction
* Unstable angina
* Stroke or TIA
* Decompensated heart failure requiring hospitalization
* Class III-IV heart failure
*Mobitz type 2 AV block

AE:
* Increase in LFTs
* Upper respiratory tract infections
* Headache
* Lymphopenia

Warnings:
-Not rec in pregnancy
-PML, PRES
-BP, hepa, resp

Question 20

Ozanimod only

Answer 20

CI: sleep apnea and MAOi

Avoid high tyramine foods

Question 21

IBD Advance Age and Cancer

Answer 21

Age
* Vedolizumab and ustekinumab preferred

Cancer
* Melanoma history (avoid TNF)
* Active or recent malignancy
(Hold while on chemo)
(Vedolizumab if treatment needed)