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PHRM 864 > IBD > Flashcards

IBD Flashcards

1
Q

what is ulcerative colitis

A

mucosal inflammation confined to rectum and colon

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2
Q

what is Crohns disease

A

transmural inflammation affecting anywhere from mouth to anus

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3
Q

what drugs may trigger UC and CD

A

NSAIDS
antibiotics
avoid use of NSAIDs

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4
Q

which disease is fistula and strictures more common

A

Crohns

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5
Q

what can happen as a complication of UC and CD

A

hepatobiliary
ocular effects
arthritis - bone dx and osteo
anemia
coagulation
derm conditions

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6
Q

what lab may be used to check for UC and CD vs IBS

A

fecal calprotectin

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7
Q

cigarette smoking is risk factor in which dx

A

Crohns

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8
Q

cigarette smoking protective in which dx

A

UC

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9
Q

rectal involvement common in which dx

A

UC

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10
Q

perianal dx common in which dx

A

Crohns

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11
Q

sulfasalazine contains what ingredients

A

sulfapyridine
mesalamine

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12
Q

what does sulfapyridine do in sulfasalazine

A

inactive
carries drug to colon
responsible for side effects

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13
Q

what does mesalamine (5-ASA) do in sulfasalazine

A

active component
exerts local action
anti-inflammatory effects

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14
Q

what dosage form most effective of mesalamine

A

topical (oral is absorbed in small intestine not colon)

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15
Q

can you use oral mesalamine with topical?

A

yes

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16
Q

what dosage forms does mesalamine come in

A

oral (EC)
topical
suppository

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17
Q

sulfasalazine side effects (8)

A

N/V
headache
anorexia
rash
thrombocytopenia
hepatotoxicity
anemia
hypersensitivity to sulfa

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18
Q

what to monitor if taking sulfasalazine

A

CBC and LFTs
every other week for 3 months

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19
Q

drug interactions with sulfasalazine

A

NSAIDs/anticoag/antiplatelets increase bleeding risk

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20
Q

if patients develop bad side effects to sulfasalazine what can they try?

A

mesalamine

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21
Q

drug interaction with mesalamine

A

NSAIDs/antiplatelt/antiocoag bleed risk
H2RA/PPI - might affect release

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22
Q

use of corticosteroids in IBD

A

induction of remission

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23
Q

corticosteroid options

A

rectal hydrocortisone
PO budesonide
PO prednisone or prednisolone
IV methylprednisolone or hydrocortisone

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24
Q

rectal hydrocortisone absorption

A

systemic absorption possible

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25
Q

budesonide absorption

A

extensive first pass
minimal systemic

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26
Q

budesonide brands

A

Enterocort pH >5.5
Uceris pH > 7

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27
Q

budesonide drug interactions

A

CYP3A4 inhibitors (grapefrutit, ketoconazole)
increase systemic exposure

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28
Q

short term adverse effects of corticosteroids

A

hyperglycemia
gastritis
mood changes
elevation of BP

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29
Q

long term adverse effects of corticosteroids

A

osteoporosis
obesity
HPA suppression
aseptic necrosis
cataracts
growth failure

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30
Q

supplements to give while on corticosteroids

A

vitamin D 800 U/day
calcium 1000-1500 mg/day
bisphosphonates for >3 month, recurrent use, osteo pt

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31
Q

what might we monitor with corticosteroids and who

A

bone mineral density (DEXA scan)
>60 year
risk osteo
> 3 month use
reccurent users

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32
Q

immunosupressants used in IBD

A

methotrexate
azathiopurine
mercaptopurine
cyclosporine

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33
Q

when do we use azathiopurine or mercaptopurine in IBD

A

failure on ASA
dependent or refractory on steroids

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34
Q

azathiopurine and mercaptopurine induction or maintenance of remission?

A

maintain remission

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35
Q

how long do we use mercaptopurine and azathiopurine

A

long term (weeks to months)

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36
Q

side effects of azathiopurine and 6 mercaptopurine

A

N/V/D
anorexia
stomatitis
bone marrow supression
hepatotoxicity
fever, rash, arthralgia, pancreatitis

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37
Q

monitoring for azathiopurine and mercaptopurine

A

TPMT
CBC
LFTs

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38
Q

cyclosporine use in IBD

A

induce remission in UC

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39
Q

how long to use cyclosporine in IBD

A

short term
bridge therapy

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40
Q

when to give cyclosporine in IBD

A

refractory/dependent on steroids

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41
Q

side effects of cyclosporine

A

nephrotoxicity
neurotoxicity
HTN, hyperlipidemia, hyperglycemia
GI upset, gingival hyperplasia, hirsutism

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42
Q

monitoring for cyclophosporine

A

BP
BUN/SCr
LFTs
trough concentration

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43
Q

drug interactions for cyclosporine

A

CYP3A and Pgp substrate
increase conc: azole, macrolide, CCBs, grapefruit
decrease conc: phenytoin, rifampin

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44
Q

methotrexate used in which disease for what

A

Crohns
induce remission

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45
Q

methotrexate dosage form

A

SQ/IM

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46
Q

methotrexate adverse effects

A

bone marrow supression
N/V/D
stomatitis
cirrhosis
teratogenic
rash
pulmonary pneumonitis

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47
Q

contraindications to methotrexate

A

pregnancy
pleural effusions
chronic liver disease/ alcohol abuse
immunodeficiency
blood dyscrasias
leukopenia
CrCl < 40 ml/min

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48
Q

TNF alpha inhibitors

A

infliximab
adalimumab
golimumab
certolizumab pegol

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49
Q

infliximab MOA

A

TNF alpha inhib

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50
Q

adalimumab MOA

A

TNF alpha inhib

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51
Q

golimumab MOA

A

TNF alpha inhib

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52
Q

certolizumab pegol MOA

A

TNF alpha inhib

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53
Q

infliximab disease states IBD and uses

A

CD and UC
mod to severe
induction and maintenance

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54
Q

infliximab dosage form

A

IV infusion

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55
Q

risk of what increased with infliximab and azathiopurine?

A

HSTCL

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56
Q

what could we combine with TNF inhibitors to decrease risk of antidrug antibodies

A

azathiopurine
mercaptopurine
methotrexate

57
Q

adalimumab disease states IBD and use

A

CD and UC
induction and maintenance of remission
poor response to infliximab

58
Q

adalimumab dosage form

A

SQ injection

59
Q

golimumab disease states IBD and use

A

UC
induction and maintenance

60
Q

certolizumab pegol disease states IBD and use

A

CD
induction and maintenance

61
Q

natalizumab MOA

A

anti alpha integrin

62
Q

vedolizumab MOA

A

anti alpha 4b7 integrin
gut selective

63
Q

natalizumab disease states IBD and use

A

CD
induction and maintenance remission
fail TNF alpha inhibs

64
Q

what agents can we not use with natalizumab

A

TNF alpha inhibs
immunosupressants

65
Q

vedolizumab disease states IBD and use

A

UC and CD
induction and remission

66
Q

natalizumab dosage form

A

IV infusion

67
Q

ustekinumab MOA

A

IL-12 and IL23 antagonist

68
Q

risankizumab MOA

A

IL-23 antagonist

69
Q

mirikizumab MOA

A

IL-23 p19 antagonist

70
Q

ustekinumab disease states IBD and use

A

CD and UC
induction and maintenance

71
Q

risankizumab disease states IBD and use

A

CD and UC
induction and maintenance

72
Q

mirikizumab disease states IBD and use

A

UC
induction and maintenance

73
Q

tofacitinib MOA

A

oral JAK inhibitor

74
Q

updacitinib MOA

A

oral JAK 1 inhibitor

75
Q

ozanimod MOA

A

oral SP1 inhibitor

76
Q

etrasimod mOA

A

oral SP1 inhibitor

77
Q

tofacitinib disease states IBD and use

A

UC
induction and maintenance ONLY if failed TNF alpha inhibitor

78
Q

updactinib disease states IBD and use

A

UC
CD
induction and remission
only if fail a TNF alpha inhibitor

79
Q

ozanimod disease states IBD and use

A

UC
induction and maintenance

80
Q

etrasimod disease states IBD

A

UC
induction and maintenance

81
Q

TNF inhibitors class side effects (7)

A

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

82
Q

monitoring for TNF inhibitors baseline

A

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes
LFTs

83
Q

monitoring for natalizumab

A

neuro for PML !!!!!
CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes
LFTs

84
Q

side effects natalizumab

A

PML
infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

85
Q

what do we test for prior to natalizumab therapy

A

JC antibody - predicts increased risk of PML

86
Q

vedolizumab side effects

A

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

87
Q

vedolizumab monitoring

A

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes
LFTs

88
Q

what can we use with vedolizumab

A

methotrexate
azathiopurine
6 mercaptopurine

89
Q

ustekinumab side effects

A

cutaneous cell carcinoma
neurotoxicity
CV events

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

90
Q

ustekinumab monitoring

A

skin
CV
neuro

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes
LFTs

91
Q

risankizumab side effects

A

hepatotoxicity/ inc LFTs
inc lipids

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

92
Q

risankizumab monitoring

A

LFTs

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes

93
Q

mirikizumab side effects

A

increase in LFTs / hepatotox

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

94
Q

mirikizumab monitoring

A

LFTs

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes

95
Q

what to consider if loss of treatment response?

A

TDM
check anti-drug antibodies and drug concentration
adalimumab and infliximab

96
Q

what drug levels would be a PK issue?

A

sub therapeutic

97
Q

what drug levels would be a PD issue?

A

therapeutic

98
Q

what to do if pt has subtherapeutic drug levels and antibodies present?

A

immune mediated PK failure
switch to diff agent in same class

99
Q

what to do if pt has subtherapeutc drug levels and no antibodies present?

A

non-immune mediated PK failure
dose increase

100
Q

what to do if pt has therapeutic drug levels and no antibodies

A

mechanistic failure
switch to diff agent in diff class

101
Q

what to do if pt has therapeutic drug levels and antibodies

A

test again: false positive?
if still positive switch to diff class

102
Q

when can we not switch to a biosimilar?

A

if failure on the Brand name

103
Q

can we use tofacitinib with other drugs?

A

not biologics or immunosupressants

104
Q

can we use updacitinib with other drugs

A

no biologics or immunosupressants

105
Q

tofacitinib side effects

A

neutropenia
black box warning: increase in mortality, CV events, clots, malignancies if CV risk
upper respiratory infections

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

106
Q

tofacitinib monitoring

A

skin checks
lipids

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolytes

107
Q

upadacitinib side effects

A

neutropenia
anemia
increased LFTs
upper respiraotry
acne
black boxed warning inc risk mortality, CV risk, clots, malignancy

infections
infusion related reactions
risk malignancy
HSTCL
demyelinating disease
CHF exacerbation
hepatotoxicity

108
Q

upadacitinib monitoring

A

lipids
skin exams

CXR
PPD
Hep B, C
s/sx infection
UA
CBC
SCr
electrolyte

109
Q

which drugs are teratogenic

A

upadacitinib
methotrexate

110
Q

ozanimod side effects

A

like biologics

PML
brady/AV delays
LFT increase
increase BP
decreased FEV1
macular edema
RPLS

111
Q

ozanimod dosing consideration

A

7 day titration

112
Q

ozanimod monitoring

A

BP
spirometry
ECG
optho

113
Q

etrasimod monitoring

A

BP
spirometry
ECG
ortho

114
Q

etrasimod side effects

A

brady/AV delays
inc LFTs
inc BP
decreased FEV1
macular edema
RPLS

115
Q

ozanimod and etrasimod can not be used with what

A

immunosupressives

116
Q

ozanimod contrainidcated for who

A

CV event in past 6 months
sleep apnea
MAOi

117
Q

etrasimod contraindicated for who

A

CV event in past 6 months (stroke, TIA, MI, HF, angina)

118
Q

ozanimod drug interactions

A

adrenergic/serotenergic drugs
MAOis
CCBs/BBs
tyramine foods

119
Q

mild-moderate UC symptoms

A

4-6 stool/day
minimal systemic symptoms

120
Q

left sided UC mild-moderate treatment

A

enema
oral mesalamine
topical mesalamine

121
Q

proctitis UC treatment mild-moderate dosage forms

A

mesalamine suppository

122
Q

mild-moderate UC treatment first line extensive dx

A

oral 5-ASA or mesalamine
CR budesonide

123
Q

can we use a combo of ASAs

A

yes, oral and topical

124
Q

in mild-moderate UC, if unresponsive to 5-ASA what do we do?

A

change formulation
high dose mesalamine + Rectal mesalamine
CR budesonide
oral prednisone
topical corticosteroids

125
Q

CR budesonide limited to how long

A

<8-16 weeks

126
Q

moderate to severe UC symptoms

A

4-6 stool per day
+/- blood in the stool
systemic symptoms

127
Q

moderate to severe active flare treatment

A

PO prednisone
TNF alpha inhibs / biologics

128
Q

what drugs should we not use in mod-severe UC induction

A

methotrexate
thiopurine monotherapy

129
Q

can we use thiopurines in mod to severe UC

A

yeah in maintenance

130
Q

moderate to severe maintenance treatment

A

TNF alpha inhibs, vedolizumab, ustekinumab with azathioprine potetially

131
Q

severe fulminant UC symptoms

A

6-10 BMs per day, blood, systemic

132
Q

severe-fulminant UC treatment induction

A

parenteral corticosteroids (methylpred or hydro)
TNF alpha inhibs
cyclosporine

133
Q

UC maintenance of remission drugs

A

what we used to induce
mesalamine - mild
biologic
thiopurines

134
Q

mild - moderate CD treatment induction

A

sulfasalazine if colonic - not great
CR budesonide

135
Q

moderate-severe CD treatment induction

A

PO prednisone
IV methylprednisolone/hydrocrotisone
infliximab/adalimumab + azathioprine (naive to biologics)

136
Q

thiopurines not reccommended for what

A

monotherapy in UC and CD moderate to severe

137
Q

cyclosporine not used for what

138
Q

severe- fulminant CD treatment induction

A

IV methypred or hydro
infliximab or TNF

139
Q

moderate CD remission tx

A

thiopurine
methotrexate
TNF alpha antags
(inflix or adal with thiopurine if naive to biologics or immuno)

PHRM 864 (28 decks)

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