IBD

Question 1

What is the UC pathophysiology?

Answer 1

-appears in rectum and colon, more superficial in nature
-can cause hemorrhoids, anal fissures, perirectal abscesses, toxic megacolon, increased risk for colon cancer

Question 2

What are the drug related causes for IBD?

Answer 2

NSAIDs (can be causative) and antibiotics (not causative but associated)

Question 3

What is the CD pathophysiology?

Answer 3

-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

Question 4

what are the nonpharmacological therapy recommendations for IBD?

Answer 4

-no specific diet shown to be helpful
-probiotic therapy maybe helpful
-surgery

Question 5

What are the ASA agents?

Answer 5

sulfasalazine (sulfapyridine + mesalamine)
-mesalamine (need to find right formulation to deliver to correct area)
-Apriso, Lialda, Pentasa, Asacol HD and Delzicol, Olsalazine, Balsalazide

Question 6

What role do corticosteroids play in IBD?

Answer 6

-induction of remission
-hydrocortisone, budesonide, prednisone, prednisolone
-must supplement calcium and Vitamin D

Question 7

What role does Azathioprine (AZA) and mercaptopurine (6-MP) have in IBD?

Answer 7

-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)

Question 8

What role does Cyclosporine have in IBD?

Answer 8

-not recommended for CD only UC
-can be effective in inducing remission
-cannot be used long term

Question 9

What role does Methotrexate play in IBD?

Answer 9

-used in CD mainly
-may have steroid sparing effects and help induction

Question 10

What biologics are used for UC only?

Answer 10

golimumab (simponi), mirikizuman (Omvoh), tofacitinib (Xeljanz), Ozanimod (Zeposia), Estrasimod (Velsipity)

Question 11

What biologics are used for CD only?

Answer 11

certolizumab (Cimza), natalizumab (Tysabri)

Question 12

What biologics can be used for both CD and UC?

Answer 12

infliximab (remicade), adalimumab (Humira), vendolizumab (Entyvio), ustekinuman (Stelara), risankizumab (Skyrizi), updacitinib (Rinvoq)

Question 13

What medications have anti TNF activity?

Answer 13

infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), Certrolizumab (Cimzia)

Question 14

What medications have IL-12 and IL-23 antagonism?

Answer 14

ustekinumab (Stelara)
risankizumab (Skyrizi) - IL-23 antagonist
mirikizumab (Omvoh) - IL-23 antagonist

Question 15

what medications are JAK inhibitors?

Answer 15

tofacitinib (Xeljanz), upadacitinib (Rinvoq)

Question 16

what medications are S1P receptor modulators?

Answer 16

ozanimod (Zeposia), estrasimod (Velsipity)

Question 17

What is the mechanism of action of natalizumab (Tysabri)?

Answer 17

anti-a-subunit of integrin’s (prevents leukocyte adhesion/migration)

Question 18

What is the mechanism of action of vedolizumab (Entyvio)?

Answer 18

anti-a4b7 integrin antibody (found on T-lympthocytes)

Question 19

What are the class ADRs for TNF inhibitors?

Answer 19

-increased risk of infections
-injection site reactions
-risk of malignancy (lymphoma)
-hepatosplenic T-cell lymphoma (HSTCL) risk
-risk of demyelinating disease
-can exacerbate HF

Question 20

What are the AE’s of concern for Natalizumab (Tysabri)?

Answer 20

-PML
-related to antibody JC virus (can test for this)

Question 21

What are the AE’s of concern for Ustekinumab (Stelara)?

Answer 21

-cutaneous cell carcinoma in pts w risk factors
-possible neurotoxicity (RLPS, PRES)

Question 22

What are the AE’s of concern for Risankizumab (Skyrizi)?

Answer 22

-headache, nasopharyngitis, arthralgia, abdominal pain, anemia, nausea
-potential hepatotoxicity
-increases in lipids

Question 23

What are the AE’s of concern for Mirikizumab (Omvoh)?

Answer 23

-headache, arthralgia, rash, injection site reactions, URI infections
-potential hepatotoxicity

Question 24

how do you interpret the TDM of biologics?

Answer 24

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

Question 25

What AE’s are of concern with tofacitinib (Xeljanz)?

Answer 25

-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)

Question 26

What is the black box warning for Tofacitinib (Xeljanz)?

Answer 26

increased mortality and thrombosis in RA patients 50+ with 1 or more CV risk factor

Question 27

What is contraindicated in patients who take Ozanimod (Zeposia)?

Answer 27

-pts who experienced a CV event in last 6 months
-some types of arrhythmias
-with severe untreated sleep apnea
-taking an MAO inhibitor

Question 28

What AE’s are of concern in Ozanimod (Zeposia) and Estrasimod (Velsipity)?

Answer 28

-liver injury/elevated transaminases
-increase in BP
-respiratory effects
-potential risk of PML
-macular edema
-RPLS/PRES

Question 29

What is the drug interaction of note for Ozanimod (Zeposia)?

Answer 29

MAO inhibitors are CI
strong CYP2C8 inhibitors increases exposure of drug
strong CYP2C8 inducers decreases exposure of drug (reduces efficacy)

Question 30

What is the contraindication associated with Estrasimod (Velsipity)?

Answer 30

CI in patients who had a CV event in last 6 months or arrhythmias

Question 31

What is indicated for patients with mild-moderate UC?

Answer 31

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

Question 32

What is indicated for moderate-severe UC?

Answer 32

moderate can use (Mesalamine) 5-ASA therapy
-corticosteroids
-consider TNF-a inhibitors/biologics
+ combination of vedolizumab (Entyvio), ustekiumab (Stelara), thiopurines or MTX

Question 33

What is indicated for severe-fulminant UC?

Answer 33

-parenteral corticosteroids
-think about being NPO
-consider TNF-a inhibitors or cyclosporine in pts unresponsive to IV steroids

Question 34

What is indicated for remission in UC?

Answer 34

-can use either an ASA, TNF-a antagonist, azathiopurine or 6-MP

Question 35

What is indicated for mild-moderate CD?

Answer 35

-can try budesonide, antibiotics
-can try sulfasalazine or mesalamine derivatives however low efficacy

Question 36

What is indicated for moderate-severe CD?

Answer 36

-systemic corticosteroids
-potentially early biologic therapy may be helpful (TNF antagonists)
-infliximab or adalimumab + thiopurine
-MTX can be used for induction and remission

Question 37

What is indicated for Severe-fulminant CD?

Answer 37

-consider NPO
-parenteral corticosteroids
-consider infliximab or other biologic if not considered previously

Question 38

What is indicated for remission in CD?

Answer 38

AZA and 6-MP, MTX (SQ only), TNF-a antagonists