IBD Part 3 - Management Approach Flashcards
IBD
Goals for Treatment:
Active Disease | | Induce remission | Prevent Complications | V Disease in Remission | V Maintain remission Prevent relapse Prevent complications
Simplified approach to stepwise treatment of IBD
Surgery ^ Biologics ^ Immunomodulators ^ Prednisone Budesonide ^ 5-ASA Anatibotics
see slide 6
see slide 6
Approach now is “Treat to Target” especially
for CD:
§ Combination in improvement in:
• clinical symptoms and
• endoscopic findings.
§ Can use biomarkers such as ESR, CRP (C-reactive protein), fecal calprotectin
§ The goal is “mucosal healing”
Clinicians’ guide to the use of fecal calprotectin to identify and monitor disease activity in inflammatory bowel disease
see slide 8
< 50-100 ug/g quiescent disease likely –> cont tx
100-250: inflamm possible, further testing
> 250: active inflamm likely –> optimaize tjherapy to address inflamm
Disease Classification of UC
see slide 9
Mild disease: < 4 stools per day \+/- blood in stools no systemic symptoms no increase ESR
Moderate: 4 - 6 stools per day \+/- blood in stools no systemic symptoms no increase in ESR
Severe: > 6 stools per day \+ blood systemic symptoms increase in ESR
Partial Mayo Scoring Index Assessment for Ulcerative Colitis Activity
see slide 10
stool freqency
rectal bleeding
physician global assessment (normal, mild, moderate, severe)
Management of UC
See Figure 1 Management of UC
Mild to mod –> start with oral aminosalic_+/- topicals
No response add budesonide
More mod or severe start predisione
taper
§ If proctitis or distal colitis: For mild to moderate disease consider rectal products as first choice (either
aminosalicylate or corticosteroid rectal products)
• If moderate to severe, could use rectal products in combination with oral.
Disease Classification of CD
Mild to Moderate:
• ambulatory patients able to tolerate oral
• none of the following: dehydration, high fever, abdominal tenderness, painful mass or >10% weight loss
Moderate-Severe Disease:
• failed to respond to treatment for mild-moderate disease or
• fever, weight loss, abdominal pain, N, V, or anemia
Severe-Fulminant Disease:
• persistent symptoms despite steroids as outpatient or
• high fever, persistent vomiting, intestinal obstruction, rebound tenderness, cachexia, or evidence of abscess.
Harvey-Bradshaw Index (HBI) - A simple index of Crohn’s disease activity
see slide 14
Management of CD
See Figure 2 Management of CD
Consider:
DIFFERENCE aminosalicylates dont work as well in CD compared to UD
May need oral budesonide
Immunosppressants used as maintenance therapy more
§ Antibiotics for patients with primarily perianal or colonic involvement, or patients with fistulas
§ Anti-TNF therapy can be considered to treat patients with fistulas who do not respond to standard therapy.
Nutrition Management
Malnutrition may be common (25 – 80%):
- decreased intake and malabsorption
Nutrition support is important – to meet nutrition requirements and prevent nutrient deficiencies:
- avoid foods that worsen symptoms (ie spicy, high fat foods, caffeine, etc)
- patients at risk for osteoporosis – ensure calcium and Vitamin D
- multivitamins
Bowel rest may be required in acute situations:
- Oral enteral nutrition
- Total parenteral nutrition (IV) to meet nutritional requirements - may induce short-term remission in CD
Fish oils:
- some benefit
- short chain fatty acids
Probiotics:
In the last couple of days Nancy has had a fever (38.4C) and has been unable to keep anything down because of nausea.
Bowel movements now are at 10 or so a day. Nancy is
classified to have severe Crohn’s disease and is admitted to hospital. You are the pharmacist working on the GI unit.
What would you recommend as drug treatment for Nancy?
???
Monitoring IBD
Efficacy parameters:
§ Improvement in symptoms – diarrhea, abdominal pain,
blood in stools, etc
§ Improvement in extra-intestinal symptoms
§ Signs of anemia – ie Hgb, symptoms (fatigue, etc)
§ ESR, CRP, fecal calprotectin
§ No complications from disease
§ Prevention of relapse