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
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
Moderate-Severe Active CD
immunomodulator (AZA and 6-MP) monotherapy not
recommended to induce remission (may help
maintain remission after induced w steroids, may be
steroid sparing)
v may use monotherapy in maintenance of remission
* MTX (up to 25 mcg weekly IM or SC) may be used
to induction (esp in steroid-dependent CD) and for
maintaining remission
* cyclosporine should NOT be used for CD
* 5-ASA or sulfasalazine should not be used
Severe-Fulminant CD
persistent sx/systemic toxicity despite corticosteroid
or biologic txt, cachexia, rebound tenderness,
obstruction, or abscess; CDAI > 450
* require inpatient tx
* consider NPO (bowel rest)
* supportive care
* parenteral corticosteroids (if no abscess)
v methylprednisolone (16-20 mg q 6 h) or hydrocortisone
(100 mg q 8 h)
v generally treat 3-7 days (then transition to PO)
* may consider infliximab (or other biologic) if not
attempted prior
v infliximab may be preferred if fulminant
