IBD Flashcards
What is the UC pathophysiology?
-appears in rectum and colon, more superficial in nature
-can cause hemorrhoids, anal fissures, perirectal abscesses, toxic megacolon, increased risk for colon cancer
What are the drug related causes for IBD?
NSAIDs (can be causative) and antibiotics (not causative but associated)
What is the CD pathophysiology?
-appears anywhere in GI tract, fistulas are common, nutritional deficiencies are common, hepatobiliary complications, ocular complications, bone and joint complications (arthritis), hematologic and coagulation complications
what are the nonpharmacological therapy recommendations for IBD?
-no specific diet shown to be helpful
-probiotic therapy maybe helpful
-surgery
What are the ASA agents?
sulfasalazine (sulfapyridine + mesalamine)
-mesalamine (need to find right formulation to deliver to correct area)
-Apriso, Lialda, Pentasa, Asacol HD and Delzicol, Olsalazine, Balsalazide
What role do corticosteroids play in IBD?
-induction of remission
-hydrocortisone, budesonide, prednisone, prednisolone
-must supplement calcium and Vitamin D
What role does Azathioprine (AZA) and mercaptopurine (6-MP) have in IBD?
-can be used for maintenance treatment after induction on steroids; for pts who have failed 5-ASA tx
-worry abt life threatening anemias (monitor TPMT)
What role does Cyclosporine have in IBD?
-not recommended for CD only UC
-can be effective in inducing remission
-cannot be used long term
What role does Methotrexate play in IBD?
-used in CD mainly
-may have steroid sparing effects and help induction
What biologics are used for UC only?
golimumab (simponi), mirikizuman (Omvoh), tofacitinib (Xeljanz), Ozanimod (Zeposia), Estrasimod (Velsipity)
What biologics are used for CD only?
certolizumab (Cimza), natalizumab (Tysabri)
What biologics can be used for both CD and UC?
infliximab (remicade), adalimumab (Humira), vendolizumab (Entyvio), ustekinuman (Stelara), risankizumab (Skyrizi), updacitinib (Rinvoq)
What medications have anti TNF activity?
infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), Certrolizumab (Cimzia)
What medications have IL-12 and IL-23 antagonism?
ustekinumab (Stelara)
risankizumab (Skyrizi) - IL-23 antagonist
mirikizumab (Omvoh) - IL-23 antagonist
what medications are JAK inhibitors?
tofacitinib (Xeljanz), upadacitinib (Rinvoq)
what medications are S1P receptor modulators?
ozanimod (Zeposia), estrasimod (Velsipity)
What is the mechanism of action of natalizumab (Tysabri)?
anti-a-subunit of integrin’s (prevents leukocyte adhesion/migration)
What is the mechanism of action of vedolizumab (Entyvio)?
anti-a4b7 integrin antibody (found on T-lympthocytes)
What are the class ADRs for TNF inhibitors?
-increased risk of infections
-injection site reactions
-risk of malignancy (lymphoma)
-hepatosplenic T-cell lymphoma (HSTCL) risk
-risk of demyelinating disease
-can exacerbate HF
What are the AE’s of concern for Natalizumab (Tysabri)?
-PML
-related to antibody JC virus (can test for this)
What are the AE’s of concern for Ustekinumab (Stelara)?
-cutaneous cell carcinoma in pts w risk factors
-possible neurotoxicity (RLPS, PRES)
What are the AE’s of concern for Risankizumab (Skyrizi)?
-headache, nasopharyngitis, arthralgia, abdominal pain, anemia, nausea
-potential hepatotoxicity
-increases in lipids
What are the AE’s of concern for Mirikizumab (Omvoh)?
-headache, arthralgia, rash, injection site reactions, URI infections
-potential hepatotoxicity
how do you interpret the TDM of biologics?
if ADAs are detectable + sub-therapeutic drug levels = change to alternate drug in same class
if ADAs are detectable + therapeutic drug levels = repeat TDM levels, switch to out of class biologic agent
if ADAs are undetectable + sub-therapeutic drug levels = dose escalate
if ADAs are undetectable + therapeutic drug levels =PD issue= switch out of class biologic agent
What AE’s are of concern with tofacitinib (Xeljanz)?
-diarrhea, elevated cholesterol, headache, herpes zoster (shingles), increased creatine phosphokinase, nasopharyngitis, rash, URI
-rare ones inlcude: malignancy (lymphoma and other), serious infection, neutropenia, lypersensitivity (angioedema, urticaria)
What is the black box warning for Tofacitinib (Xeljanz)?
increased mortality and thrombosis in RA patients 50+ with 1 or more CV risk factor
What is contraindicated in patients who take Ozanimod (Zeposia)?
-pts who experienced a CV event in last 6 months
-some types of arrhythmias
-with severe untreated sleep apnea
-taking an MAO inhibitor
What AE’s are of concern in Ozanimod (Zeposia) and Estrasimod (Velsipity)?
-liver injury/elevated transaminases
-increase in BP
-respiratory effects
-potential risk of PML
-macular edema
-RPLS/PRES
What is the drug interaction of note for Ozanimod (Zeposia)?
MAO inhibitors are CI
strong CYP2C8 inhibitors increases exposure of drug
strong CYP2C8 inducers decreases exposure of drug (reduces efficacy)
What is the contraindication associated with Estrasimod (Velsipity)?
CI in patients who had a CV event in last 6 months or arrhythmias
What is indicated for patients with mild-moderate UC?
oral or topical ASAs
-combo of oral and topical may be more effective with left-sided/extensive
-if refractory then budesonide or corticosteroids are an alternative
What is indicated for moderate-severe UC?
moderate can use (Mesalamine) 5-ASA therapy
-corticosteroids
-consider TNF-a inhibitors/biologics
+ combination of vedolizumab (Entyvio), ustekiumab (Stelara), thiopurines or MTX
What is indicated for severe-fulminant UC?
-parenteral corticosteroids
-think about being NPO
-consider TNF-a inhibitors or cyclosporine in pts unresponsive to IV steroids
What is indicated for remission in UC?
-can use either an ASA, TNF-a antagonist, azathiopurine or 6-MP
What is indicated for mild-moderate CD?
-can try budesonide, antibiotics
-can try sulfasalazine or mesalamine derivatives however low efficacy
What is indicated for moderate-severe CD?
-systemic corticosteroids
-potentially early biologic therapy may be helpful (TNF antagonists)
-infliximab or adalimumab + thiopurine
-MTX can be used for induction and remission
What is indicated for Severe-fulminant CD?
-consider NPO
-parenteral corticosteroids
-consider infliximab or other biologic if not considered previously
What is indicated for remission in CD?
AZA and 6-MP, MTX (SQ only), TNF-a antagonists
