IBD III Flashcards
Mild-Moderate Active UC
- left sided disease within reach of ___
- proctitis within reach of ___
- extensive disease, pancolitis (i.e.,
proximal disease, beyond splenic
flexure) requires ___ tx
- enemas
- suppositories
- systemic
Mild-Moderate Active UC
oral and/or topical ASAs
- if extensive disease: ___ 5-ASA
- left sided disease, topical mesalamine ___ (1 g/day)
- proctitis: mesalamine ___ (1 g/day)
- combo of ___ and ___ may be more effective for pts with left-sided/extensive disease
- oral
- enema
- suppository
- oral, topical
Mild-Moderate Active UC
if oral tx:
- ___ derivatives better tolerated than ___
- sulfasalazine: 2-6 g/day in divided doses
- mesalamine derivatives: 2-3 g/day
consider compliance, convenience, financial resources in product choice
* once daily dosing preferred
- mesalamine, sulfasalazine
Mild-Moderate Active UC
if unresponsive to 5-ASA, can consider changing ___
* if unresponsive to standard-dose 5-ASA or moderate disease activity, AGA recommends high-dose ___ (> __ g/day) plus rectal ___
formulation
mesalamine, 3, mesalamine
Mild-Moderate Active UC
CR ___ is alternative (AGA also now
includes ___ as an option)
- especially when ___ to oral or topical 5-ASAs (can add to 5-ASA)
- limit budesonide use to < __ - __ weeks
PO corticosteroids ( ___ 40-60 mg/day) may be used for patients refractory to ASAs
* topical corticosteroids (foams, enemas, suppository) are effective for distal disease (ie, ___ , or ___ )
- budesonide, prednisone
- nonresponsive
- 8-16
- prednisone
- left sided, proctitis
Mild-Mod. Active UC
T or F: oral and topical mesalamine should not be used together
FALSE: Remember: combo
oral and topical mesalamine can be more effective
Moderate-Severe Active UC
- 4-6 stools per day, +/- blood in stool, some systemic symptoms
- 5-ASA therapy possible for moderate, but not ___ disease
- systemic corticosteroids (PO prednisone 40-60 mg/day)
- for moderate can use oral ___
consider ___ inhibitors/biologics (potentially newer small molecules) in pts unresponsive to ASAs/other therapy, pts who are steroid dependent, pts who fail steroids
- severe
- budesonide
- TNF-a
Moderate-Severe Active UC
TNF inhibitor (3)
anti-integrin (1)
IL12/IL-23 inhibitors (3)
JAK inhibitor (2)
- black box warning, only if failed TNF inhibitor
SP1 inhibitor (2)
- infliximab, adalimumab, golimumab
- vedolizumab
- ustekinumab, mirikizumab, risankizuab
- upadacitinib, tofacitinib
- ozanimod, etrasimod
Moderate-Severe Active UC
AGA suggests against using ___ for induction or maintenance
___ monotherapy is option
thiopurine monotherapy should not be used for ___
- thiopurine monotherapy is option for ___
- AGA makes no recommendation regarding biologics monotherapy vs thiopurine monotherapy for maintenance
- methotrexate
- biologic
- induction
- maintenance
Moderate-Severe Active UC
AGA recommends combining TNF-antagonists, vedolizumab, or ustekinumab with ___ or ___ rather than monotherapy
- patients with less severe disease, or those who place relative value on minimizing ADRs vs maximizing efficacy may choose biologic monotherapy
AGA suggests ___ use of biologics (with/without immunomodulators) rather than gradual step-up (very low quality evidence)
- especially in moderate-severe disease at high risk of colectomy
- those with less severe disease who place a higher value on the safety of 5-ASA agents may prefer gradual step up
- thiopurines, MTX
- early
Moderate-Severe Active UC
in patients who have achieved remission with biologic agents and/or immunosuppressives or tofacitinib, AGA recommends ___ continuing
5-ASA for induction or maintenance
AGAINST
Mod. -Severe Active UC
T or F: certolizumab is approved for UC
FALSE
IMPORTANT: certolizumab is NOT approved for UC; golimumab IS approved for UC
Severe-Fulminant UC
require inpatient tx
- consider ___ (bowel rest)
parenteral corticosteroids
- methylprednisolone (16-20 mg q 6 h, AGA recommends 40-60 mg/day)
- hydrocortisone (100 mg q 8 h)
- generally treat __ - __ days (then transition to PO)
consider TNF-α inhibitors ( ___ ) or ___ in pts unresponsive to IV steroids
- cyclosporine: start IV, transition to PO, with transition to ___ or ___
- effective, but may delay rather than prevent colectomy
___ has similar efficacy to ___
- NPO
- 3-7
- infliximab, cyclosporine
- 6-P, AZA
- infliximab, cyclosporine
UC: Maintenance of Remission
generally use an ___ , a TNF-α antagonist
( ___ and ___ ), ___ , or ___
- choice depends on part in the tx required to induce remission
- no role for ___ ; ___ not studied
ASAs
- newer ___ derivatives better tolerated than ___ (2-3 g/day mesalamine equiv)
- use mesalamine ____ (if left-sided disease) or ___ (if proctitis)
- may use ___ of topical/systemic (more effective than either alone)
in pts who are steroid dependent or unresponsive to ASAs
- ___ or 6- ___ (slow to work: 3-6 months)
TNF-α antagonist for pts who required a TNF-α antagonist for induction (or who fail ___ )
* possibly with AZA
* ___ , ___ , or ___
- ASA, infliximab, adalimumab, AZA, 6-MP
- corticosteroids, budesonide
- mesalamin, sulfasalazine
- enemas, suppositories
- combo
- AZA, 6-MP
- AZA
- infliximab, adalimumab, golimumab
UC: Maintenance of Remission
anti-integrin (1)
IL12/IL-23 inhibitors (3)
JAK inhibitor (2)
* black box warning, only if failed TNF inhibitor
SP1 inhibitor (2)
- vedolizumab
- ustekinumab, mirikizumab, risankizumab
- upadacitinib, tofacitinib
- ozanimod, etrasimod
Mild-Moderate Active CD
___ marginally effective for treating symptoms of mild/mod colonic CD
- not isolated small bowel CD
- does not result in mucosal ___
mesalamine derivatives have ___ efficacy, no longer recommended, should not be used
- despite this, mesalamine derivatives frequently tried since well tolerated/familiar
- consider formulation and site of action
- sulfasalazine
- healing
- minimal
Mild-Moderate Active CD
controlled release ___
- option for pts with ilealeocecal ( ___ ) or ___ sided disease
antibiotics
- e.g. metronidazole +/- ciprofloxacin
- variable efficacy, possible option if perianal disease, fistulizing disease, unresponsive to sulfasalazine
- not recommended as primary therapy
- budesonide
- distal, right
Mild-Moderate Active CD
T or F: mesalamine has no efficacy in CD
True
- sulfasalazine has marginal efficacy
Moderate-Severe Active CD
failed treatment for mild/mod disease, systemic symptoms (fever, wt. loss, abd. pain/tenderness, anemia, vomiting, diarrhea, etc)
- systemic corticosteroids ( __ prednisone 40-60 mg/day)
- tx until resolution of sx and resumption of ___
- may be more effective than ___
hospitalized patients may receive ___ corticosteroids
- methylprednisolone (16-20 mg q 6 h) or hydrocortisone (100 mg q 8 h)
early ___ therapy (with/without immunomodulators) may be beneficial
- PO
- weight gain
- budesonide
- IV
- biologic
Moderate-Severe Active CD
TNF-α antagonists effective
- can use in patients failing ___ tx, ___ dependent pts
- ___ + AZA (or possibly MTX) may be more effective than either alone
___ may be used
* SC administration
* possible option in pts who lose response to infliximab
AGA suggests ___ or ___ plus thiopurine for induction and maintenance over monotherapy in those naïve to biologics and immunomodulators
___ may be used (AGA recommends other agents over certolizumab based on results of meta analysis)
- immunosuppressive, steroid
- infliximab
- adalimumab
- infliximab, adalimumab
- certolizumab
Moderate-Severe Active CD
Agents targeting leukocyte trafficking
- ___ - with or without immunomodulator
- ___ - not preferred, only use for maintenance if JC negative
IL-12/IL-12 and IL-23 antagonists
- ___ and ___
JAK inhibitor
- ___ : if failed TNF inhibitor
- vedolizumab
- natalizumab
- ustekinumab, risankizumab
- upadacitinib
Moderate-Severe Active CD
immunomodulator (AZA and 6-MP) ___ not recommended to induce remission (may help
maintain remission after induced w ___ , may be
steroid sparing)
- may use monotherapy in maintenance of remission
___ (up to 25 mcg weekly IM or SC) may be used
to induction (esp in steroid-dependent CD) and for
maintaining remission
* ___ should NOT be used for CD
* ___ or ___ should not be used
- monotherapy, steroid
- MTX
- cyclosporine
- 5-ASA, sulfasalazine
Severe-Fulminant CD
persistent sx/systemic toxicity despite corticosteroid
or biologic tx, cachexia, rebound tenderness,
obstruction, or abscess; CDAI > 450
* require inpatient tx
* consider ___ (bowel rest)
* supportive care
___ corticosteroids (if no abscess)
- methylprednisolone (16-20 mg q 6 h) or hydrocortisone
(100 mg q 8 h)
- generally treat 3-7 days (then transition to PO)
may consider ___ (or other biologic) if not
attempted prior
- may be preferred if fulminant
- NPO
- parenteral
- infliximab
CD: Maintenance of Remission
minimal evidence ___ and PO ___ derivatives are effective
- may try due to favorable adverse effect profile
- not recommended in moderate-severe CD
no role for systemic ___
- ___ has minimal long-term efficacy à not recommended for >4 months
- sulfasalazine, mesalamine
- corticosteroids
- budesonide
CD: Maintenance of Remission
___ and ___ are effective
- esp. in steroid-induced or infliximab-induced remission
MTX
- alternative to AZA and 6-MP, esp. in pts w initial response to MTX
- SQ only (PO not recommended)
AZA, 6-MP
CD: Maintenance of Remission
___ antagonists are options for CD maintenance
- ADA suggests use of infliximab or adalimumab in combination with ___ or ___ in patients who are naïve to biologics and immunomodulators
- certolizumab
- ant-integrin: ___
- Il-12/IL-23 antagonists: ___ , ___
- ___ not recommended
clinical controversy: bottom-up or top-down approach
* in moderate-severe disease, AGA suggest early introduction with a biologic +/- and immunomodulator vs delaying their use while trying 5-ASAs and/or corticosteroids
- TNF-a
- infliximab, adalimumab
- vedolizumab
- ustekinumab, risankizumab
- natalizumab
Follow-up: Monitor and Evaluate
- resolution of active disease
symptoms (24-48 hours for
___ patients, 7-14 days for ___ ) - evaluate symptoms, labs for
efficacy and toxicity - monitor for ADRs
- TDM
- assess adherence
- determine need for dose adjustment (e.g. corticosteroids)
- hospitalized, outpatients
