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Pharm II > IBS/IBD > Flashcards

IBS/IBD Flashcards

1
Q

what has Contributing Factors: Genetics, motility factors, inflammation, colonic infections, mechanical irritation to local nerves, stress

A

IBS

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2
Q

what has Lower abdominal pain, disturbed defecation, and bloating with absence of structural or biochemical explaining factors

A

IBS

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3
Q 
what has 
-Diarrhea Symptoms > 3 stools/d
Extreme Urgency
Mucus passage
-Constipation Symptoms < 3 stools/wk
Straining
Incomplete Evacuation
-Psychological
Depression
Anxiety
A

IBS

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4
Q

what are 3 comorbid conditions with IBS

A

Fibromyalgia
Functional dyspepsia
Chronic Fatigue Syndrome

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5
Q

MANNING Chronic Or recurrent abdominal pain > __months with 2 or more of the following:

A 
6 mo
Ab pain relieved by defecation
Ab pain associated with more freq stool
Ab distention
Feeling of incomplete evacuation after defecation
Mucus in stools
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6
Q

ROME III

Recurrent abdominal pain or discomfort > __ days/month in the last __ months associated with 2 or more of the following:

A

3 days for 3 mo
Relieved with defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool

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7
Q

for constipation predom IBS how do you treat? 4

A

Stress management and patient education
Increase dietary fiber and fluid
Next add bulk forming laxative and consider antispasmodics
Add serotonin-4 agonist (Tegaserod)

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8
Q

for diarrhea predom IBS how do you treat? 4

A

Stress Management and Patient Education
Lactose and caffeine free diet as well as avoiding other causative foods
Add loperamide or another antispasmodic
Add 5-HT3 antagonist (Alosetron)

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9
Q

Mucosal inflammatory condition

Confined to rectum and colon

A

Ulcerative colitis

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10
Q

Transmural inflammation of GI tract

Can affect any part of GI tract

A

Crohns

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11
Q

Inflammation is limited to the mucosa; continuous pattern of involvement

A

UC

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12
Q

what has symptoms of Bloody diarrhea and abdominal pain = cardinal symptoms
Severe cases: fever, anorexia, weight

A

UC

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13
Q

what has Autoimmune pathophysiology and Inflammation occurs throughout the full thickness of the bowel wall; skip pattern of involvement; strictures, fistulas, ulcers

A

Crohn’s

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14
Q

what has cardinal symptoms of diarrhea and abdominal pain and Weight loss, vomiting, fever, perianal discomfort, bleeding = common complaints

A

Crohns

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15
Q

what bacteria 1st detected in 1980s in intestinal tissue of Crohn’s disease pts

A

Mycobacterium avium subspecies paratuberculosis (MAP)

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16
Q

what bacteria is inc in IBD? and what has no beneifit?

A 
Increase in pathogenic bacteria
Bacteroides
Escherichia coli
Decreased beneficial bacteria
Bifidobacterium
Lactobacillus species
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17
Q

what is smoking protective in?

A

UC

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18
Q

what does smoking make worse?

A

CD

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19
Q

what drugs should you avoid in IBD - 3 types

A 
Opiates
Reduce GI Motility
NSAIDS
Worsen IBD by disrupting mucosal barrier
Antidiarrheals
Loperamide, Diphenoxylate/Atropine
Risk of Precipitating Toxic Megalocolon
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20
Q

what diet improves UC? exacerbates?

A

NONE

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21
Q

what dietary measure should you avoid in UC exacerbation

A

fiber

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22
Q

what should you take during remissions of UC

A

Metamucil 1-2 x day

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23
Q

how do you treat mild to moderate UC - 4 options

A

-Sulfasalazine 4-6 g/day OR
-Mesalamine 4.8 g/day OR
-Aminosalicylate at dose equivalent to mesalamine 4.8 g/day
-OR if Distal Disease
Mesalamine Enema/Suppository
Corticosteroid Enema

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24
Q

what do you do for remission of mild to mod UC - 2 options

A

Reduce dose by half OR

With enema/ suppository: Reduce frequency to q 1-2days

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25
Q

what do you use to treat mod - severe UC

A

Sulfasalazine 4-6g/day OR Mesalamine 3-6g/day

Plus Prednisone 40-60mg/day

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26
Q

how do you treat remitted mod-severe UC

A

Taper prednisone, then reduce sulfasalazine or mesalamine after 1-2 months to approximately half

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27
Q

how do you treat refractory mod-severe UC? what should you consider if no response

A

Add Azathioprine or Mercaptopurine (6-MP) OR

Consider Infliximab if no response

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28
Q

how do you treat Severe or Fulminant Ulcerative Colitis?

A

Hydrocortisone IV

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29
Q

how do you treat remitted Severe or Fulminant Ulcerative Colitis

A

Change to prednisone add sulfasalazine or mesalamine

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30
Q

if, in Severe or Fulminant Ulcerative Colitis, there is no response for 5-7 days…

A

Cyclosporine IV 4 mg/kg/day

If no response, patient candidate for colectomy

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31
Q

can surgical resection cure UC?

A

yes High-grade dysplasia, suspected cancer

Pts with severe disease requiring high-dose steroids that can’t be tapered after 6-12 months

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32
Q

what is used in maintenance of UC? 2 options

A

Aminosalicylates and/or AZA or 6-MP

Alternative Infliximab 5mg/kg q 8 weeks

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33
Q

what are the nutritional measures for CD? 3

A

Limit fiber with cramping and diarrhea
Decrease fat intake when steatorrhea
Multivitamin with minerals daily

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34
Q

how do you treat Mild-Moderate Crohn’s if its in ileocolonic or colonic

A

Sulfasalazine 3-6 g/day or

Oral mesalamine 3-4 g/day

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35
Q

how do you treat Mild-Moderate Crohn’s if its perianal?

A

Sulfasalazine 3-6 g/day or
Oral mesalamine 3-4 g/day and/or
Metronidazole 10-20 mg/kg/

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36
Q

how do you treat Mild-Moderate Crohn’s if its in the sm bowel?

A

Oral mesalamine 3-4 g/day or
Metronidazole 10-20 mg/kg/day or
Budesonide 9mg/day

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37
Q

how do you treat mod-severe crohns?

A

add prednisone to mild-mod

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38
Q

if crohns is refractory or fistulizing

A

add infliximab

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39
Q

if crohns is not responsive after adding infliximab…

A

Adalimumab
Natalizumab
Certolizumab

40
Q

when do you taper prednisone in crohns? and add?

A

after 2-3 weeks

Add AZA, 6-MP or MTX

41
Q

how do you treat severe-fulminant crohns?

A

hydrocortisone IV

42
Q

how do you treat if severe-fulm crohns doesnt respond to hydrocortisone

A

Cyclosporin IV

43
Q

what is first line maintenance for crohns… 2nd and 3rd…

A

Azathioprine/6-MP

Infliximab 5 mg/kg IV q wk x 6, then q 8 weeks
Methotrexate 25mg IM up to 16 weeks followed by 15mg IM weekly

44
Q

what is the MOA of Sulfasalazine (Azulfidine)

A

Metabolized by intestinal bacteria to to the active component 5-aminosalicylate (5-ASA) and sulfapyridine (mesalamine)

45
Q

what are the contraind of Sulfasalazine (Azulfidine)? 2

A

Salicylate hypersensitivity

Renal impairment- Monitor SCr

46
Q

what are the ADRs of Sulfasalazine (Azulfidine)? lots

A
  • N/V, heartburn, anorexia
  • HA
  • Hypersensitivity rxns (rash, fever)-Do not use in pts with sulfa allergy
  • Blood disorders (anemia, thrombocytopenia, granulocytopenia)
  • Can impair folic acid absorption
  • Idiosyncratic rxns (hepatocellular injury, agranulocytosis, lupus-like phenomena)
  • Low sperm counts
47
Q

what is mesalamine?

A

aminosalicylate

48
Q

what are the ADRs of mesalamine?

A

Local itching and mild rectal irritation with topical enemas

Idiosyncratic rxns: pleuropericarditis, pancreatitis, nephrotic syndrome

49
Q

how id mesalamine given?

A

Mesalamine or suppositories for rectosigmoid disease

Delayed release formulations of mesalamine for Crohn’s ileitis

50
Q

what is the MOA of corticosteroids?

A

Anti-inflammatory effects
Improves Symptoms
Improves disease severity

51
Q

how do we taper corticosteroids?

A

Taper by 5mg/wk prednisone or equivalent

52
Q

how long should it take for corticosteroids to work?

A

7-14 days

53
Q

what does the Inability to taper is indicate

A

indication for amtimetabolite and/or infliximab therapy

54
Q

Parenteral steroid indicated in pts …

A

failing to respond to 7-14 days of high dose oral prednisone or equivalent

55
Q

what do you need to monitor for in corticosteroids

A

Glucose intolerance/ metabolic abnormalities
Hyperkalemia
Hyponatremia
glucose
Greater risk for adrenal insufficiency and infections
N/V
Postural hypotension

56
Q

what is long term tx of corticosteroids? what do you need to do?

A

> 3 mo bonedensity scan and annual eye exam

57
Q

what are 2 Immunosuppressives

A

6-Mercaptopurine (6-MP)
Azathioprine (Imuran)
Pro-drug metabolized to 6-MP

58
Q

what is the adv of Immunosuppressives

A

Maintenance therapy that is less toxic than chronic steroid therapy
Steroid-sparing achieve or maintain control and allow reduction or discontinuation of steroids

59
Q

what is the MOA of Immunosuppressives

A

Antagonizes purine metabolism; inhibits DNA, RNA and protein synthesis

60
Q

what is the disadv of Immunosuppressives

A

delay in onset

61
Q

what are the numerous ADRs…. BM, other inc risks? GI? Other? Infections?

A 
Bone marrow suppression 2-5%
Dose related
Managed by dose reduction/withdrawal
Leukopenia, thrombocytopenia, pancytopenia
Risk of lymphoma
4 fold increase
Pancreatitis 1.3-3.3%
Dose independent
Occurs within 3-4 weeks of start
Resolves with stopping drug
GI effects
N/V, abdominal pain
Occurs early, improves with time or with dose reduction
Other
Fever, rash, arthralgias
Dose independent
Infections
Disseminated CMV, herpes zoster, pneumonia, Q fever, viral hepatitis
Occur without leukopenia
Increased risk if combined with steroids
62
Q

what are the drug int of Immunosuppressives

A 
Inhibition of metabolism leading to increased myelosuppression
Sulfasalazine, mesalamine
Allopurinol
Aspirin
Furosemid
63
Q

what is mtx?

A

immunomodulator

64
Q

what is the MOA of mtx

A

Folic acid antagonist with anti-inflammatory effects (affects immune system??)

65
Q

what is the good thing about mtx

A

Reduces steroid needs

Improves disease control

66
Q

what are the adr’s of mtx…. lots!

A 
Nausea
Elevated transaminases
Leukopenia
N/V
Hypersensitivity pneumonitis (rare)
Hepatic fibrosis
Most significant in long term therapy
Risk with >1500 mg total cumulative dose and daily dosing
DC if moderate/severe fibrosis or cirrhosis found on biopsy
67
Q

what is contrind for mtx?

A

Absolute contraindication in pregnancy (Category X)
Stop therapy 3 months prior to conception
Folate supplementation prior to conception
Contraindicated in breastfeeding

68
Q

what are 2 cyclosporins?

A

neoral and sandimmune

69
Q

what is the MOA of cyclosporins

A

inhibits production and release of IL-2  inhibits activation of T-lymphocytes

70
Q

what is recommended for cyclosporins in tx? and remission?

A

Concomitant IV steroids recommended

Cyclosporin alone unable to maintain remission
Requires “bridging” with AZA or 6-MP
Convert IV to PO
PO dose is 2x IV dose
Wean off cyclosporin and steroids over next few months

71
Q

cyclosporins toxicity?

A 
HTN
Hypertrichosis
Electrolyte abnormalities
Nephrotoxicity
Opportunistic Infections
Requires PCP prophylaxis
72
Q

what is the MOA of Tacrolimus (Prograf)

A

inhibits T-lymphocyte activation

Fungus (streptomyces)

73
Q

what is ADRs of Tacrolimus (Prograf)

A 
Adverse Reactions: Tend to resolve with dose reductions
HA
Increased serum creatinine
Nausea
Insomnia
Leg cramps
Paresthesias
Tremors
74
Q

what are 3 monoclonal ab?

A

infliximab, adalimumab, natalizumab

75
Q

what is the MOA of infliximab?

A

Monoclonal antibody that binds to TNF-alpha

Inhibits inflammatory cytokines, inhibits leukocyte migration and activation of neutrophils

76
Q

infliximab contraind?

A 
NYHA class III/IV heart failure
Dose should not exceed 5mg/kg in other pts with congestive heart failure
Hepatitis
Reactivation of hepatitis B
Autoimmune hepatitis
Discontinue use with LFTs 5x ULN
77
Q

ab to infliximab what happens?

A

Increased risk of infusion rxn, shorter duration of response

regularly scheduled less immunogenic than episodic

78
Q

what infections may infliximab tox cause?

A

Bacterial, mycosal, mycobacterium

Higher TB rates with more extrapulmonary involvement

79
Q

what infusion rxn may infliximab tox cause?

A

During or after (1-2 hrs)
HA, dizziness, nausea, erythema at site, flushing, fever, chills, chest pain, cough, dyspnea, pruritis
Mechanism unclear- not IgE type 1
Doesn’t occur till after 1st infusion; not at every infusion

80
Q

what delayed hypersensitivities may infliximab tox cause?

A

3-14 days after infusion
Myalgia, arthralgia, fever, rash, pruritis, dysphagia, urticaria, HA
Resolve spontaneously or require steroids
Prednisone 40mg PO or methylprednisolone 100mg IV 30 min before

81
Q

what is rare with autoab to infliximab?

A

Development of drug-induced lupus rare

Reversible with DC

82
Q

what malignancy may come from infliximab tox?

A

Malignancy and lymphoproliferative disorder

Longstanding CD and tx with immunosuppression more likely to develop lymphomas

83
Q

what is the MOA of adalimumab?

A

recombinant fully-human immunoglobulin-1 anti-tumor necrosis factor (TNF)-alpha monoclonal antibody

84
Q

what should you do before tx with adalimumab

A

eval for TB

85
Q

what is the BB warning on adalimumab

A

TB, invasive fungal, other opportunistic infections

86
Q

what are other adrs of adalimumab

A

Rash, injection site rxn, HA, URI, development of autoantibodies to drug, development of anti-nuclear antibodies (ANA)
Risk of reactivating hepatitis B

87
Q

what is true aboud natalizumab? approved for? devp for?

A

Approved by FDA on 1/14/08 for “moderate to severe Crohn’s in pts with evidence of inflammation who have had inadequate response to, or are unable to tolerate conventional therapies
Pts must be enrolled in special restricted distribution program
Crohn’s Disease-Tysabri Outreach Unified Commitment to Health (CD-Touch) Prescribing Program
Originally approved June 2006 for MS

88
Q

what is the moa of natalizumab?

A

recombinant immunoglobulin-4 monoclonal antibody

89
Q

when do you DC natalizumab?

A

if no response in 12 wks, or steroids not tapered within 6 mo

90
Q

dont admin natalizumab with?

A

other immunosuppressants (6-MP, azathioprine, MTX, cyclosporin, or inhibitors of TNF)

91
Q

what is the major adr of natalizumab?

A

progressive multifocal encephalopathy

92
Q

what is metronidazole used for in IBD?

A 
Indications:
For treatment of ileocolitis or colitis
Failure to respond to sulfasalazine
For treatment of abscesses, rectovaginal fistulas, proctocolectomy wounds
Low dose maintenance
93
Q

what are the adrs of metronidazole?

A

GI upset, metallic taste, paresthesias, antabuse-like rxn

94
Q

what is cipro for in IBD

A

Effective in resistant disease when used in combination with standard tx

95
Q

when do we use metro and cipro in IBD?

A

Improve and can promote closure of fistulas

Tend to recur once drugs stopped

96
Q

what opiates are used in IBD? - diarrhea

A

Diphenoxylate/atropine, codeine, tincture of opium, paregoric, loperamide

Pharm II (8 decks)

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