IBD (UC/Crohns) Flashcards
IBD Definition
Chronic inflammatory disease of GI tract
- edema, ulceration, tissue destruction
Relapsing/remitting nature
- flare tx
- maintenance tx
IBD presentation
Diarrhea
Blood in stool
Abdominal pain
Cramping
Weight loss
Fatigue
Change in daily activities
Diagnosing IBD
Symptoms - pt age 15-30
Labs
- increased ESR and CRP (nonspecific inflammatory)
Stool studies
- increased WBC (lactoferrin, calprotectin)
Endoscopy - colonoscopy
CT scans and MRI
Ulcerative colitis
starts in rectum, spreads upwards
Proctitis = rectum only
Left sided/distal = rectum + sigmoid + descending
Extensive: past the splenic flexure
Confined to mucosa (superficial)
Continuous
Crohn’s disease
Mouth to anus, terimnal ileum especially
Deep penetration
patchy, cobblestone
Perianal involvement (fistulas and fissures)
Compications of Crohn’s disease
Malnutrition
Vitamin deficiency
Strictures
Fistulas
Complications of Ulcerative Colitis
Toxic megacolon/sepsis
Colon cancer
Colectomy (curative)
Crohn’s disease classification
Remission
Mild-moderate
Moderate-severe
Severe-fulminant
CD: remission
Asymptomatic, no sequelae, CDAI<150
CD: remission treatment
Flares: perianal fissures
- Antibiotics (Flagyl TID or Cipro BID)
- surgery
- infliximab
CD: mild-mod
CDAI 150-200
no fever
significant pain/obstruction
less than 10% weight loss
some diarrhea
CD: mild-mod treatment
Local steroid: PO budesonide (Entocort) x 8 weeks
IF COLONIC involvement –> Sulfasalazine (5-ASA)
CD: mod-severe
CDAI 220-450
failed mild-mod tx
FEVER >38F
weight loss more than 10%
abdominal pain
NV, no obstruction
ANEMIA (low hgb)
CD: mod-severe treatment
when Budesonide fail after 2-4 weeks
-> Systemic oral GC + AZA
- PO prednisone + AZA
OR
Biologic therapy + AZA
CD: Severe-Fulminant
CDAI > 450
Persistent sx despite mod-severe tx
OFTEN needs to be in HOSPITAL
HIGH fever >39F
PERSISTENT N/V
Cachexia - can’t eat
Intestinal ABCESSES
SEVERE abdominal pain
CD: severe-Fulminant
SURGERY - resect disease/obstruction
- IV steroids (hydrocortisone, methylprednisolone)
OR
- IV infliximab
+ supportive care
Maintenance therapy for Crohn’s disease
If used steroid –> give AZA for remission
If used biologic –> give biologic + AZA
if Perianal disease: abx, surgery, infliximab
UC: remission
Asymptomatic
Formed stools (not diarrhea)
NO blood
Hbg normal
Normal ESR and CRP
Fecal calprotectin 100-200
UC: mild treatment
Distal disease
1) Active (combo of ASA is best)
»Topical 5-ASA mesalamine (rectum = suppository; left sided = enema)
»Oral 5ASA
2) Maintenance:
»Topical 5ASA & PO 5ASA
Extensive (entire GI)
1) Active:
»PO 5ASA +/- Budesonide (uceris) x 8 weeks
2) Maintenance
»PO 5ASA
UC: mild
<4 stools/day
intermittend blood in stool
Hgb normal
ESR normal
CRP ELEVATED
FP ELEVATED
UC: mod-severe
> 6 stools/day
FREQUENT blood
Hgb<75% of normal
ELEVATED
- ESR
- CRP
- FP
UC: mod-severe treatment
Active
1) Local steroid: Budesonide (Uceris) +/- AZA x 8 weeks
2) Systemic steroid: Prednisone 40-60 mg +/- AZA
3) Biologic: Infliximab +/- AZA
Maintenance
- if used steroid: AZA
- if used biologic: same biologic +/- AZA
UC: fulminant
> 10 stools/day
CONTINUOUS blood
hgb < 8 (pt needs transfusion)
ELEVATED
- ESR/CRP/FP
UC: fulminant treatment
Active
1) IV steroids x 3 days (hydrocortisone/methylprednisolone)
2) IV infliximab (UC only)
3) IV cyclosporine
Surgery - colectomy
Maintenance
- Steroid: AZA
- Biologic: same biologic +/- AZA
- Cyclosporine: AZA or vedolizumab
5-ASA drugs
Sulfasalazine - sulfa carrier
Mesalamine
Olsalazine
Balsalazide - inert carrier
Mesalamine forms
Pentasa - wide GI coverage
Rowasa and Canasa - Rectal
Used more for ulcerative colitis (lower colonic)
Immunomodulator drugs
Maintain remission
Azathioprine -workhorse
6-mercaptopurine
Methotrexate - crohns only (IM/SQ =>PO)
Cyclosporine - fulminant UC
Azathioprine (AZA)
prodrug m6p
Takes 3 months to work
Steroid sparing (use less steroid)
Improve biologic efficacy (decrease ADA)
Azathioprine (AZA) monitoring
CBC Q 3 months
LFT - hepatotoxicity
Pancreatic enzymes - pancreatitis
Azathioprine (AZA) BBW
Lymphoma risk
Increased risk w/ biologic therapy use
Corticosteroids
Induction therapy
Predisone = PO
Methylpred, HC = IV
Budesonide = PO (CD maintenance)
- Enterocort = CD; terminal ileum
- Uceris = UC; colon
CD: enteric gram-negative/anaerobe abx
Metronidazole
Ciprofloxacin
3rd gen cephalosporins
Infliximab
Remicade
IV = infusion center
Adalimumab
Humira
SQ, use at home, better QoL
Biologic drugs
Infliximab IV
Adalimumab SQ
Certolizumab
Golimumab
Biologic drug BBW
Infections (TB, fungal, bacteria, viral, etc)
PPD, chest X-ray, screen for HBV, HCV, HIV at baseline
Malignancies - lymphoma
Integrin inhibitors
Natalizumab
Vedolizumab
Natalizumab BBW
progressive multifocal leukoencephelopathy w/ reactivation of john cunningham virus
REMS program
interleukin inhibitors
Ustekinumab (IL12, IL23) - stelara
Risankizumab (IL23) - skyrizi
non- biologics
Tofacitinib PO (JAKi)
Upadacitinib PO (JAKi)
Ozanimod PO (S1P)
Limited to TNFa failure
Jak inhibitor BBW
Cancer
Cardiac (MACE)
thrombosis
infections
death
Infusion-related reactions
IV products
- Methylprednisolone, hydrocortisone - both
- Infliximab - both
- Cyclosporine - full UC
SQ better QoL
Adalimumab - Both
Certolizumab - CD
Golimumab - UC
Which 5ASA also used for CD, what kind?
Sulfasalazine for colonic involvement
Methotrexate and tacrolimus used in which IBD?
Crohns
What are metronidazole and Cipro for in IBD?
CD fissure/fistulas
use with infliximab and surgery
How long for budesonide to work?
2-4 weeks
How long is budesonide therapy?
PO, 8 weeks
Jak stat inhibitors are used in which IBD?
Ulcerative colitis
Vedolizumab: what class and indication?
Integrin inhibitor, for ulcerative colitis maintenance after induction with cyclosporine
When do we not use AZA for active UC?
Active fulminant
- use IV steroids x3 days, IV infliximab, IV cyclosporine
or surgery
When do we not use AZA for active CD?
Mild-moderate cases
Severe-fulminant cases
- IV steroids, IV infliximab
or surgery
5ASA MOA
acts topically to reduce inflammation (PG) locally
Decreases PG, LT, lipoxygenase, NFkB
Pentsa (mesalamine)
PO jejunum
Canasa (mesalamine)
Suppository, rectum
Rowasa (mesalamine)
Enema, rectal + distal
Comparing 5ASA options
Mesalamine: many doses
Sulfasalazine: cheap, lots of ADR
Osalazine: diarrhea, less frequent BID
Balsalazide: better tolerated, TID
