IBD 2 - Crohn’s Disease Flashcards
What is CDAI? (1)
Crohn’s Disease Activity Index
What factors is the CDAI score based on? (8)
Number of liquid stools
Abdominal pain
General wellbeing
Number of extraintestinal complicatiosn
Use of antidiarrhoeals
Presence of abdominal mass
Haematrocrit
Weight
What are the severity range of CDAI? (3)
Remission < 150
Moderate > 220
Severe > 300
Outline the treatment regimen for inducing remission in patient with CD. (3)
1st line: Corticosteroids
2nd line: Thiopurines or MTX
3rd line: Biologics
Explain the use of corticosteroids in inducing remission in patients with CD. (1)
Offer monotherapy with a conventional glucocorticosteroid (Prednisolone, methylprednisolone or IV hydrocortisone) to induce remission in people with a 1st presentation or a single inflammatory exacerbation of CD in a 12 month period.
What are the types of CS preparations used for inducing remission in CD? (3)
- IV:
- Severe
- Hydrocortisone 100mg QDS (can go up to 500mg QDS) - Oral:
- Prednisolone 30-40mg daily (morning)
- Consider oral Budesonide (Entocort or Budenofalk) if Prednisolone is CI/declined. May be effective in ileal disease due to site of release.
- Tapering - more severe the exacerbation, slower the schedule should be. Average 5mg / week.
- May need to adjust / slow down to cover introduction of aza/6mp (3 months to effect) - Topical:
- Suppositories = proctitis
- Enemas effective up to splenic flexures.
Explain the use of Budesonide for inducing remission in a patient with CD. (2)
For people with 1 or more of distal ileal, ileocaecal or right sided colonic disease who decline, can’t tolerate or in whom a conventional glucocorticosteroid is c/i.
Budesonide is less effective than a conventional glucocorticosteroid but may have fewer s/e.
Explain the use of Azathioprine or 6-MP as add on treatment for inducing remission in patients with CD. (2)
Aza/6MP considered if there are 2 or more inflammatory exacerbations in a 12 month period or
Glucocorticosteroid dose can’t be tapered.
Explain the use of 5-aminosalicylate for inducing remission in patient with CD. (2)
In people who decline, can’t tolerate or conventional glucocorticosteroid is c/i, consider 5-ASA for a first presentation or a single inflammatory exacerbation in 12 month period.
5-ASA is less effective than a conventional glucocorticosteroid or Budesonide but may have fewer side effects than a conventional glucocorticosteroid.
Explain the use of biologics as add on treatment for inducing remission in patients with CD. (2)
Used as monotherapy if 1st and 2nd line options are CI or not tolerated.
Can be used with immunomodulators.
Explain the use of MTX as add on treatment for inducing remission in patients with CD. (2)
AZA + 6-MP aren’t tolerated / c/i.
Explain the prescribing safety of thiopurines. (3)
AZA: Prodrug metabolised by xanthine oxidase to mercaptopurine.
6-MP: Metabolite of AZA, sometimes better tolerated and more effective for some patients.
Assess TPMT activity before offering AZA/MP:
- Don’t offer AZA/6-MP, if TPMT activity is deficient (very low or absent)
- Consider AZA or 6-MP at a lower dose if TPMT activity is below normal but not deficient.
What pre-treatment bloods/monitoring for thiopurines? (4)
FBC
LFTs
CRP
U&E/renal function
What pre-treatment screening is considered for thiopurines? (4)
Hepatitis B + C
HIV
Varicella
EBV
What is the dosing regimen for Azathioprine? (1)
2-2.5mg/kg daily
What is the dosing regimen for 6-MP? (1)
1-1.5mg/kg daily
What counselling is given to patients on thiopurines? (4)
Blood tests: weekly for 1 month then 3 months.
Avoid direct sunlight
Avoid live vaccines
Increased risk of infection, cancer and bone marrow suppression.
- Patient should be warned about the possibility of bone marrow suppression e.g. infections or unexplained bleeding or bruising
- Should report to Rxer immediately.
What are the common interactions of thiopurines? (4)
Allopurinol: High risk of increased toxicity, life threatening reaction.
Warfarin: reduced INR, monitor closely and may take 3 months for effect.
Trimethoprim / co-trimoxazole: Increased risk of thombocytopenia/neutropenia = avoid.
Clozapine: High risk of agranulocytosis = avoid.
What are the prescribing safety of MTX? (2)
Use if AZA/6-MP is ineffective or aren’t tolerated.
Rx folic acid 5mg once weekly alongside usually 2 to 3 days after MTX dose.
What are the monitoring requirements for MTX? (2)
FBC and LFTs before and every month.
What warning should you be aware of MTX? (4)
Weekly dosing
One strength to be Rx only.
Px advised of dose and frequency.
Report signs of blood/liver toxicity and respiratory effects.
What are the signs of blood toxicity when taking MTX? (3)
Sore throat
Bruising
Mouth Ulcers
What are the signs of liver toxicity when using MTX? (4)
Nausea
Vomiting
Abdominal Discomfort
Dark Urine
What are the respiratory s/e of taking MTX? (1)
SOB
What are the common adverse effects of MTX? (4)
Bone marrow suppression:
- Occurs abruptly.
- A clinically significant drop in WCC or platelet count calls for immediate withdrawal of MTX and supportive therapy.
Liver toxicity:
- Treatment not started or discontinued if any liver function abnormalities develop.
Pulmonary toxicity:
- Monitor for symptoms, discontinue if pneumonitis suspected.
Gastrointestinal toxicity:
- Withdraw if stomatitis develops.
What factors can increase the risk of MTX toxicity? (3)
Advanced age
Renal Impairment
Concomittant use with another anti-folate drug e.g. trimethoprim.
Give e.g. of common interactions with MTX. (2)
Drugs that reduce renal excretion of MTX e.g. NSAIDs .
Drugs with anti-folate activity e.g. Trimethoprim.
Explain the effect of TNF-a in CD. (3)
Tumour necrosis factor alpha:
- Proinflammtory mediator
- Overexpressed in IBD
- Partly responsible for chronic inflammatory processes in the intestinal tissue.
Explain the general use of biologic therapy in CD. (2)
Inducing remission as monotherapy or in combination with an immunosuppressant.
What are biologics? (3)
Large, complex molecules.
Chemically synthesised:
- Made from protein and other substances that occur in nature.
- Manufactured in a living system e.g. modified plant and animal cells.
Give e.g. of biologics used in IBD. (5)
Infliximab (Remicade)
Adalimumab (Humira)
Vedolizumab (CD) - Entyvio
Ustekinumab (CD) - Stelara
Golimumab (UC) - Simponi
Rx by brand
Explain the use of Infliximab and Adalimumab in IBD tx. (3)
Treatment options for adults with severe active CD.
Whose disease hasn’t responded to conventional therapy OR
Who are intolerant of or have c/i to conventional therapy.
What pre-treatment checks is considered for Infliximab and Adalimumab? (11)
CXR - TB
QuantiFERON Gold Tests - TB
Hep B+C
HIV
Varicella
HSV
EBV
Baseline CRP, FBC, U&Es, LFTs, ANA.
Weight (dosing)
Vaccine advice
Urine sample.
What is the main risk associated with using biologics in IBD? (1)
Can alter the immune system. If patient has latent TB it can cause reactivation. Hence, screening must be performed to rule TB before initiation. If identified, TB is treated first.
What ongoing monitoring is considered for biologics? (5)
FBC, ESR, CRP, LFTs every 6 months
ANA levels - annually
When should Infliximab and Adalimumab be given? (2)
As planned course of treatment until tx failure including need for surgery. OR
Until 12 months after start of tx, whichever is shorter.
What are the c/i of using Infliximab + Adalimumab? (9)
Crohn’s related abscess
Moderate to severe HF
Possible demyelination / multiple sclerosis
TB
Lymphoma
Recurrent infections
Hepatitis B Infection (Adalimumab only)
Evidence of active infection.
When would you consider stopping or withholding Infliximab + Adalimumab? (6)
Patient presents with an active infection.
Transaminases are raised >3xULN
Severe injection site reaction
Rash
Low neutrophil count
Ahead of elective surgery
What are the s/e of Infliximab + Adalimumab? (9)
Headaches
Sore throat
Swallowing difficulties
Aches and pains in muscles/joints
Leg/face swelling
Nausea, Diarrhoea, Abdominal pain
Worsening heart problem
Liver dysfunction
How long will it take for the s/e of Infliximab /Adalimumab to disappear? (1)
6 months.
What is the main risk associated with taking Infliximab + Adalimumab? (1)
Immunosuppression:
- Advise px to tell their doctor immediately if they notice any skin rashes, hives or frequent infections even if they occur several weeks after stopping Infliximab or Adalimumab treatment.
What are the long term effects of using Infliximab & Adalimumab? (3)
Higher risk of developing lymphoma.
Patients with COPD and heavy smokers, higher risk of cancer.
May exacerbate multiple sclerosis.
What are the main features of Biosimilars? (2)
Brand Rx only.
Switching: same dose/intervals, patient choice and stable clinical response.
Explain the cancer risks associated with CD tx. (4)
Higher risk of colon cancer due to IBD.
Immunomodulators:
- 4x high risk of lymphoma.
- Non-melanoma skin cancer
- Cervical dysplasia
Anti-TNF:
- High risk of melanoma
Combination of both therapies, higher risk of solid organ malignancy..
Outline the process of maintenance therapy of CDs. (3)
Patient specific
No tx.
Tx:
- AZA or 6MP/ MTX
- Biologics:
- Continue if needed to induce remission.
Give e.g. of issues associated with medicine management. (7)
Steroids: BM, K levels + supplements
OP: prevention + treatment
Patient counselling on AZA/6-MP
Monitoring: TMPT interpretation/checking, FBC, LFTs, U+Es.
Interactions awareness
Pregnancy/conception
Screening + vaccination
What 5 vaccines should be considered for all patients with IBD? (5)
Influenza (inactivated) vaccine annually.
Pneumococcal vaccine
Hep. B vaccine (in all HBV seronegative patients)
HPV (Human Papillomavirus)
Varicella zoster vaccine (if no Hx of shingles or chicken pox if VZV seronegative patients)
