IBD Therapy Flashcards by Stuart Thomson

What are the aims of IBD therapy?

control inflammation + heal mucosa, restore normal bowel habit, improve quality of life

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What are the therapeutic strategies?

Lifestyle advice, drugs, surgery

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What therapy options are there for UC?

5ASA (mesalazine)
Steroids
Immunosuppresants
Anti-TNF therapy

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What are the therapy options for CD?

Steroids,
Immunosuppresants
ANti-TNF therapy

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What is the preferred action for 5ASA?

topical effect, anti-inflammatory properties, reduces risk of colon cancer, side effects are diarrhoea, idiosyncratic nephritis

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5-Aminosalicylic acid (5-ASA)

Oral - prodrugs, pH dependant release, delayed release.

Topical - suppositories and enemas

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What types of 5ASA are there?

Sulphasalazine, Balsalazide, Mazavant, mesalazine, pH release (asacol), delayed release (pentasa)

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What 5ASA gets only released in the Colon?

Salazopyrin

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What 5ASA gets released in the colon and the Ilium?

Balsalazide

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What 5ASA gets released in the colon, the Ilium and the jejunum?

Asacol Salofalk

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What 5ASA gets released in the colon, the Ilium, the jejunum and the duodenum?

Pentasa

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Give two examples of Corticosteroids

Prednisolone (oral) and Budesonide (topical)

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What is the purpose of Corticosteroids

To induce remission

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Should corticosteroids be stopped immediately?

No, reduced over a period of 6-8 weeks

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How many CD patients become steroid-dependant?

28% at one year

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Name some musculoskeletal steroid side effects

Avascular necrosis

osteoporosis

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Name some Metabolic side effects of Steroids?

Weight gain
Diabetes
Hypertension

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Name some other steroid side effects

Acne
Thinning of skin
Cataracts
Growth failure

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What immunosuppressant’s are used for IBD?

Azathioprine
Mercaptopurine
Methotrexate

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What is the main metabolism of Azathioprine?

AZA –> 6-MP –> 6-TGN (active)

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What are side products of Azathioprine metabolism?

imidazole, 6-MMP (via TPMT) and 6-TU (via Xanthine Oxidase)

Describe the effects of Azathioprine

Slow onset (16w)
TPMT activity contributes to toxicity 
Avoid co-prescription of allopurinol (XO inhibitor) and regular blood monitoring required

What are Azathioprine side effects?

Pancreatitis
Leucopaenia
Hepatitis
Small risk of lymphoma, skin cancer

What is Anti-TNF?

Tumour Necrosis Factor a = proinflammatory cytokine.
Chimeric (infliximab; IV infusion
Humanised (adalimumab, S/C injection)
Promotes apoptosis of activated T-lymphocytes
Rapid onset of action

Remision rates of Infliximab

30-40%

Deescribe Anti-TNF

Rapid mucosal healing in responders | remission duration 8-12 weeks

Safety of Anti-TNFa

Infusion reactions - 13% HACA +ve Infection - numerous Cancer - Lymphoma and solid tumours TB

When use Anti-TNFa?

Long term strategy, supportive etc. refractory/fistulating disease and exclude TB

Explain the 2 types of IBD surgery

Emergency - failure to respond to medical therapy, small bowel obstruction, abscess and fistulae Elective - Failure to respind to medical therapy, Dysplasia of colon mucosa

Describe surgery for CD

Minimise amount of bowel resected, non curative, try not to induce short gut syndrome

Describe surgery for UC

Curative, option of permanent ileostomy or restorative protocoloectomy and pouch

What are the elective surgeries for CD?

Resection Stricturoplasty Fistulas Anal disease

What are the elective surgeries for UC?

Proctocolectomy with end ileostomy Proctocolectomy with ileorectal anastomosis With a pouch

What are the emergency surgeries for IBD?

Sub total colectomy for UC Resection for CD Diagnostic laparoscopy Rectal/anal disease

Why may you do elective surgery in UC?

``` Medically unresponsive disease Intolerability Dysplasia/malignancy growth retardation in children Attempted resolution of extra-intestinal disease ```

Difference between colostomy and ileostomy?

colostomy - left, flush, stool | ileostomy - right, spouted, effluent

Problems with a pouch?

``` Average 6 bowel movements a day leakage incontinence nocturnal incontinence failure and reversed to ileostomy ```

Complications of a pouch?

Immediate - haemorrhage and enterotomy - Anaphylaxis Early - urinary dysfunction, wound infection, pelvic abscess, anastomotic leak - Artelectasis, Ileus and portal vein thrombosis Late - Impotence, Infertility, Pouchitis - DVT/PE, small bowel obstruction

How do you assess acute attack severity?

``` ESR haemoglobin bloody stools temperature heart rate ```

How should you treat a rectal flare up?

With predfoam enemas etc. DO NOT ENTER

What is the cancer risk with IBD?

4% = CRC with UC | by 30 yrs, up to 18%

Signs of toxic megacolon

``` Sepsis Distension Pain Requires decompression may perforate and be fatal ```

What is Rigler's sign?

Gas on outside of bowel wall

Considerations for CD surgery

DVT steroids/immunosupp nutritional status Electrolytes

What are indications for CD surgery?

``` Stenosis causing obstruction Enterocutaneous fistulas Intra-abdominal fistulas Abscesses Bleeding Free perforation ```

Surgical treatment for Multisite disease

Stricturoplasty of lesions Heineke-Mikulicz Balloon dilatation

What are concerns for abscesses and fistulas?

SNAP - sepsis, nutrition, anatomy and plan. | Intra-abdominal and enterocutaneous

What are the types of CD colonic surgeries?

Emergency, segmental, total, panproctocolectomy, pouches

Types of perianal disease?

Primary lesions - fissure/ulcer Secondary lesions - abscess, tages, fistula Incidental lesions - pilesm hidradenititis

What is good treatment for Fistulas?

Seton. | Surgery is also good (lay open, stoma if bad enough)