IBDFC Flashcards
Inflammatory Bowel Disease pathophysiology and types
Group of inflammatory conditions of the colon and small intestine
Ulcerative colitis and Crohn’s disease
sx of ibd
Symptoms: cramping, bloody diarrhea, fever, weight loss; Crohn’s can also cause malabsorption and anal fissures
tx of ibd
Treatment goals is to suppress inflammation to reduce Symptoms
food triggers of ibd
Food triggers include beans, alcohol, lactosecontaining dairy products, cabbage, broccoli. NOT MEAT
Ulcerative Colitis (UC) def
Mucosal inflammation confined to the rectum and colon with superficial ulcerations
sx of UC
Symptoms: abdominal cramping, frequent bowel movements, weight loss, fever, tachycardia
Crohn’s Disease (CD) def
Transmural inflammation of the GI tract that can affect any part (from mouth to anus), although 2/3 of cases are in the ileum
bowel wall injury is extensive and the intestinal lumen is often narrowed
sx of croh’s
Symptoms: abdominal pain, frequent bowel movements, weight loss/malnutrition, malaise
tx of UC
Treatment
Antispasmodics my be useful in Mild UC (dicyclomine)
with acute flareups of either condition, short courses of oral or IV steroids are used
with more moderate Symptoms, aminosalicylates (sulfasalazine or mesalamine) are used to control inflammation
crohns tx
Crohn’s , in moderatesevere cases, may require a stronger immunosuppresive agent (thioprine, 6MP, methotrexate)
severe UC or crohns tx
In severe UC or Crohn’s cases TNFblockers (infliximab) may be needed
Antidiarrheals & Antispasmodic
Antidiarrheals: loperamide (Imodium), bismuth subsalicylate (PeptoBismol, BSS), diphenoxylate/atropine (Lomotil)
Antispasmodic: dicyclomine (Benyl)
when to use antidiarrheals and antispasmotides in IBD
used for Mild symptom control: diarrhea, cramping/GI spasms
Loperamide (Imodium) MOA
antidiarrheal moa unkonw
CI loperamide
CI: abdominal pain without diarrhea; children 2 days
SE loperamide
SE: abdominal cramping, constipation, nausea
dose loperamide for IBD
Dose: 4 mg after first loose stool, then 2 mg after each subsequent stool (Max: 16 mg/day)
Bismuth Subsalicylate (PeptoBismol, BBS) USE
antidiarrheal
ci of pepto
CI: children with viral infections due to risk of Reye’s; salicylate allergy; history of severe GI bleed or coagulopathy
se of pepto
SE: black tongue/stool, hearing loss, tinnitus (toxicity(
dose of pepto
Dose: 2 tbsp or 2 tabs every 3060 minutes (Max 8 doses/day & 2 days of therapy)
Diphenoxylate/Atropine (Lomotil) USE
antidiarrheal
CI of lomotil
CI: children < 2; C. diff.; obstructive jundice
se of lomotil
SE: sedation, constipation, urinary retention, tachycardia, blurred vision, xerostomia, dizziness, depression
dose of lomotil for ibd
Dose: 5 mg QID (Max 20 mg/day)
Dicyclomine (Bentyl) USE
Antispasmodic
CI of dicyclomine
CI: GI obstruction; severe ulcerative colitis; reflux esophagitis; narrowangle glucoma; myasthenia gravis; infants <6 months
se of dicyclomine
SE: (anticholinergic) dry mouth, blurry vision, urinary retention, constipation, dizziness, lightheadedness, drowsiness, xerostomia, confusion, tachycardia
dose of dicyclomine
Dose: 1020 mg QID (Max 160 mg/day)
when to take dicyclomine
Take 3060 minutes before meals
Steroids
Prednisone, budesonide (Entocort EC)
when to use steriuds for iBD
used to decrease severity of acute attack (use until acute flares resolve or weight is regained)
short term se of steroids
SE (shortterm): increased appetite/weight gain, fluid retention, emotional instability, insomnia, GI upset
longerm se of steroids
SE (longterm): adrenal suppression/Cushing’s syndrome, impaired wound healing, HTN, hyperglycemia, cataracts, osteoporosis
which steroid undergoes much first pass metabolism
Budesonide: undergoes extensive firstpass metabolism so lower systemic exposure; do not crush tablet; is preferred agent if disease is in ileum or ascending colon; 3A4 substrate. less side effects but less effective than prednisone. use for 8 weeks for active tx.
Maintenance Therapy for IBD
Aminosalicylates: mesalamine, 5ASA, sulfasalazine
Immunosuppressive Agents: azathioprine, 6mercaptopurine, methotrexate
Monoclonal antibodies to TNF: infliximab, certolizumab, adalimumab, natalizumab
moa mesalamine
aminosalicilate
Mesalamine brands and formulations
Asacol, Pentasa, Lialda, Canasa (suppository), Rowasa (enema)
mesalalamine
SE: headache GI upset, loss of appetitie, N/V/D, photosensitivity > 10% chance of rash.
mx for mesalamine
Monitor: renal function, CBC, Symptoms of IBD
what meds to avoid with mesalamine
Best to avoid concomittant use with antiacids, H2RAs, or PPIs
whu use mesalamine over sulfasalazine
Better tolerated that sulfasalazine
can you crush or chew mesalamine?
Swallow caps whole
Sulfasalazine brands
Azulfidine, SulfazinAzulfidine ENtabs
ci of sulfasalazine
CI: sulfa or salicylate allergy; GI or GU obstruction
se of sulfasalazine
SE: headache, rash, anorexia, dyspepsia, GI upset, oligosperia, folate deficiency; arthalgia, crystalluria can cause skin/urine to turn yelloworange
mx for sulfasalazine
Monitor: CBC, LFTs, Symptoms of IBD
Azathioprine brand
Azasan, Imuran
bbw of azathioprine
BBW: chronic immunospuppresion can increase risk of neoplasia; hematologic toxicities and mutagenic potential
se of azathioprine
SE: GI upset, rash, increase LFTs, hematologic toxicities
mx azathioprine
Monitor: LFTs, CBC, renal function
what deficiency is important in azathioprine
Genetic deficiency of thiopurine methytransferase (TPMT) will be more sensitive to myelosupprssive effects
6Mercaptopure
Purinethol
6MP bbw
BBW: chronic immunospuppresion can increase risk of neoplasia; hematologic toxicities and mutagenic potential
se of 6mp
SE: GI upset, rash, increase LFTs, hematologic toxicities
mx 6mp
Monitor: LFTs, CBC, renal function
deficiency important in 6mp
Genetic deficiency of thiopurine methytransferase (TPMT) will be more sensitive to myelosupprssive effects
Methotrexate brand
Rheumatrex, Trexall
mtx bbw
BBW: renal; pneumonitis; bone marrow suppression; mucositis/stomatitis; dermatologic reactions
ci of mtx
CI: pregnancy; alcoholism; chronic liver disease; blood dyscrasias
se of mtx
SE: nausea, diarrhea, mucositis/stomatitis, skin reactions
mx of mtx
Monitor: CBC, LFTs, renal function
antidote of mtx
Antidote: leucovorin or levoleucovorin
Infliximab brand
Remicade
MOA of infliximab
CHIMERIC monoclonal antibody to TNF (adlimubam and azathioprine are fully HUMANIZED so less antibody production)
bbw of infliximab
BBW: infections (TB, bacterial sepsis, invasive fungal); malignancy
ci of infliximab
CI: doses >5mg/kg in moderatesevere HF
warnings of infliximab
Warnings: TNF inhibitors can cause demyelinating disease, hepatitis B reactivation, heart failure, hepatotoxicity, lupuslike syndrome, and infections
se of infliximab
SE: infections, headache, abdominal pain; infusion rxns: hypotension, fever, chills, pruritis
mx of infliximab
Monitor: vitals, TB test, S&S of infection, CBC, LFTs, HBV, HF, malignancies
how to infuse infliximab
Should be infused within 3 hours of reconstitution; 2 hour infusion (requires a filter) (IV only)
Certolizumab brand
Cimzia
moa of certolizumab
PEGlinked HUMANIZED Monoclonal antibody to TNF
bbw of certolizumab
BBW: infections (TB, bacterial sepsis, invasive fungal); malignancy
warnings of certolizumab
Warnings: TNF inhibitors can cause demyelinating disease, hepatitis B reactivation, heart failure, hepatotoxicity, lupuslike syndrome, and infections
se of certolizumab
SE: infections, headache, abdominal pain; infusion rxns: hypotension, fever, chills, pruritis
how to take certolizumab
Inject SQ into the abdomen or thigh
how to store certolizumab
Vials refrigerated; reconstituted vial are good for 24 hours in refrigerator or 2 hours at room temp
Adalimumab
Humira
moa adalimumab
HUMANIZED Monoclonal antibody to TNF
bbw adalimumab
BBW: infections (TB, bacterial sepsis, invasive fungal); malignancy
warning of adalimumab
Warnings: TNF inhibitors can cause demyelinating disease, hepatitis B reactivation, heart failure, hepatotoxicity, lupuslike syndrome, and infections
se of adalimumab
SE: infections, headache, abdominal pain; infusion rxns: hypotension, fever, chills, pruritis
mx of adalimumab
Monitor: vitals, TB test, S&S of infection, CBC, LFTs, HBV, HF, malignancies
how to take adalimumab
Inject SQ into the abdomen or thigh
how to store adalimumab
Store in refrigerator until use
Natalizumab brand
Tysabri
moa of natalizumab
HUMANIZED Monoclonal antibody that inhibits alpha4integrin
bbw natalizumab
BBW: risk for progressive mulifocal leukoencephalopathy (PML)
warning natalizumab
Warnings: hepatotoxicity, infection
when to dc if nor response natalizumab
Discontinue if no response by week 12
program to be enrolled in for natalizumab
Must be enrolled in manufacturer TOUCH prescribing programming
when to administer natalizumab
Must be administered within 8 hours of preparation
first line for ulcerative colitis
enema or rectal mesalamine suppositites for mild/mod dz
what type of mesalamine for chron’s?
ORAL therapy with mesalamine or sulfasalizine
mesalamaine rectal suspension is called
rowasa. store at room temp. therapy can be up to 6 weeks. may have a sulfite. state if sulfa allergy. administer at night since enema once daily.