IBD therapy Flashcards
what is the lifestyle advice for IBD?
stop smoking - crohns (esp after surgery)
Diet can influence symptoms but not involved in pathogenesis (low fibre = bowel rest)
what effect does smoking have on crohns
clinical, endoscopic and surgical recurrence
what drugs are used in crohns?
all have anti-inflammatory effects depends on severity of flare Steroids (in severe/acute, not long term) immunosuppression Anti-TNF
what drugs are used in UC?
5 ASA (mesalazine)
Steroids (in severe/acute, not long term)
Immunosuppressant (step up from 5 ASA)
Anti-TNF
how does 5 ASA work?
topical effect
anti-inflammatory effects
acts at mucosal surface
reduces colon cancer risk
what are the side effects of 5 ASA?
diarrhoea in some idiosyncratic nephritis (so need to monitor renal function)
how is 5 ASA delivered?
topical - suppositories - enemas oral - prodrugs - pH dependant release - delayed release Give a combination of topical/oral in acute flare
what are some mesalazine derivative agents?
mezavant (delayed release)
Asacol (pH release)
what are the limits of topical administered drugs?
suppositories = only reach 20cm of tract but have better adhesion than enemas enemas = reflex contraction moves liquid/foam enemas proximally
when are corticosteroids used?
in acute flares
how so corticosteroids work?
anti-inflammatory
induce remission
short course - initially high dose, reduce over 6-8 weeks
Eg. prednisolone or budesomide
what are the issues with corticosteroids?
people can become dependant or resistant to the steroids
therefore used as a bridge to maintenance therapy
what are the side effects of corticosteroids?
weight gain diabetes hypertension avascular necrosis osteoporosis acne thin skin neuropsychiatric - can become manic, depressed cataracts growth failure (in children)
when are immunosupressants used?
after steroids
when more potent inflammatory suppression required
steroid sparing agents in UC
maintenance in crohns
which immunosupprssants are used?
azathioprine/merrcaptopurine
methotrexate
how do immunosupressants work?
supresses bone marrow
acts on liver
reduces number of WBCs produced
how does azathioprine work?
slow onset (16 weeks)
TPMT activity contributes to toxicity
avoid co-prescription of allopurinol (XO inhibitor)
regular blood monitoring required (due to possible effect on bone marrow/liver)
what are the side effects of azathioprine?
pancreatitis
leucopaenia
hepatitis
small risk of lymphoma, skin cancer (advice to use high spf sun cream all year round)
what are the anti-TNF drugs?
infliximab
adalinumab
how does anti-TNF work?
TNF = pro-inflammatory cytokine drug acts as antibodies to TNF - infliximab = chimeric - adalimumab = humanised promote apoptosis of activated T cells rapid onset of action
how is anti TNF used?
once settled add in th……….
how effective is infliximab?
8-12 week remission
good in crohns and UC
what are the risks with anti-TNF?
infusion reactions (already have antibodies against the drug)
infection
reactivate latent TB
Cancer (lymphoma, solid tumours)
when is anti-TNF used?
as part of long term strategy for immune suppression, surgery (crohns) and supportive therapy
refractory/fistulating disease
what are the problems with anti-TNF?
very expensive
biosimilar versions of anti-TNF now available which are cheaper
when is surgery implicated?
emergency - failure to respond to medical therapy - small bowel obstruction - abscess - fistula elective - failure to respond to medical therapy - dysplasia of colon mucosa
what is the therapy pyramid for IBD?
smoking cessation 5 ASA (UC) steroids if needed immunosuppression Anti TNF Surgery
