Inflammatory Bowel Disease Flashcards
what are the two types of inflammatory bowel diz?
Ulcerative colitis
crohn’s dz
which condition is a transmural inflammation of the GI?
Crohn’s dz
bloody diarrhea and abdominal pain indicates what?
Ulcerative colitis
Diarrhea and abdominal pain indicates what?
Crohn’s dz
common complaints of crohn’s dz
weight loss
vomiting
fever
perianal discomfort
what 2 bacteria is there an increase in (pathogenic) with IBD?
Bacteroides
E. Coli
what types patients have a generalized impaired immune response? will have decreased blood flow to sites and decrease neutrophils and inter-leukin 8
Crohn’s Dz
what dz is smoking protect for?
Ulcerative colitis
smoking makes what dz worse?
crohn’s dz
what meds should be avoided w/ IBD
Opiates
NSAIDs (disrupt mucosal barrier)
Antidiarrheals (risk of megalocolon)
with IBD will result in fistulas?
Crohn’s Dz
does any diet improve or exacerbate UC?
No
What nutritional supplements can help UC?
Reduced fiber during exacerbation
folic acid
oral iron w/ considerable rectal bleeding
metamucil
when should someone with UC take folic acid?
When leafy veggies restricted or
sulfasalazine being used
what drugs can you start someone on with mild-moderate ulcerative colitis?
Sulfasalazine
Mesalamine
Aminosalicylate
If ulcerative colitis is more distal what drugs can you give?
Mesalamine enema/ suppository
corticosteroid enema
when someone is in remission for UC what can you do?
Reduce dose by 1/2 or
reduce enema/ suppository to q 1-2 days
what should you add to treatment for moderate to severe UC.
Add prednisone (high dose)
what must you do with the prednisone to discontinue it?
Taper the dose down
when someone goes into remission after having moderate to severe UC what should you do?
Taper prednisone
REduce sulfasalazine/ mesalamine after 1-2 months to half
For refractory UC what do you add? (Not responding to normal therapy)
Azathioprine or mercaptopurine (6-MP)
infliximab (antibody)
How do you treat severe or fulminant UC?
Hydrocortisone (IV)
if remission change to prednisone add sulfasalazine or mesalamine
If someone doesn’t respond to tx of severe or fulminant UC? (within 5-7 days)
cyclosporine IV
colectomy
only cure of UC
surgery
what do you use for maintenance of UC? (takes all the time)
aminosalicylates and/or AZA or 6-MP
alternative infliximab q 8 weeks
What are beneficial nutritional measures for Crohn’s?
Limit fiber w/ cramping and diarrhea
decrease fat intake w/ steatorrhea
multivitamin w/ minerals daily
how do you treat ileocolonic or colonic crohn’s?
sulfsalazine
oral mesalamine
tx for perianal crohn’s
sulfsalazine
oral mesalamine
metronidazole
small bowel tx of crohn’s
oral mesalamine
metronidazole
budesonide
with mild-moderate crohn’s dz you give them the same tx and add what?
Prednisone
If a person isn’t responding to initial tx for Crohn’s what do you add or fistulaing dz?
Infliximab
what are 3 other drugs to use if infliximab isn’t working? for crohn’s
Adalimumab
Natalizumab
Certolizumab
once the patient responds to tx for crohn’s dz how do you treat?
Taper prednisone after 2-3 weeks
Add AZA, 6-MP or MTX
how do you tx severe fulminant crohn’s?
hydrocortisone IV
if no response switch to cyclosporin
what drugs do you d/c for crohn’s?
long term corticosteroids
what is the 1st line maintenance for crohns?
azathioprine / 6-MP
infliximab
methotrexate
name the 2 aminosalicylates
sulfasalazine
mesalamine
name 2 immunomodulators
azathiprine
6-MP
Most commonly used for inducing and maintaining remission
Aminosalicylates
how long can response take with aminosalicylates?
2-3 weeks
what metabolizes sulfasalazine to 5-ASA and mesalamine?
intestinal bacteria
C/I to sulfasalazine
salicylate hypersensitivity renal impairment (monitor SrCr)
what needs to be monitored w/ sulfasalazine?
SCr
Main ADRs with sulfasalazine
blood disorders (anemia, thrombocytopenia, granulocytopenia)
impair folic absorption
low sperm counts
what are the idiosyncratic rxs with sulfsalazine (will go away once stop taking meds)
hepatocellular injury
agranulocytosis
lupus-like phenomena
MOA of mesalamine
unclear
ADRS with mesalamine
less than sulfasalazine
local itching and mild rectal iritation
idiosyncratic rxns
how should you presibe mesalamine?
based on location (oral/ supossitory)
what drugs has there idiosyncratic rxns pleuropericarditis, pancreatitis, nephrotic syndrome
?
mesalamine
MOA of corticosteroids
anit-inflammatory effects
name some corticosteroids
prednisone budesonide prednisolone hydrocortisone methyprednisolone
what corticosteroid is in syrup?
Prednisolone
when should you taper w/ a corticosteroid.
If a patient is on the corticosteroid for more than 7 days
if you can’t taper the patient down without the patient getting sick again, what should you give?
amtimetabolite and/or infliximab
with long term use of corticosteroids what can happen?
glucose intolerance/ metabolic abnormalities
greater risk for adrenal insufficiency/ infection
if one corticosteroids for greater than 3 months what can develop?
osteoporosis
eye problems
what are 2 immunosuppressants
6-Mercaptopurine (6-MP) (pro drug)
Azathioprine
MOA of immunosuppressives
Antagonizes purine metabolism; inhibits DNA, RNA and protein synthesis
how long do immunosuppressives take to work?
weeks to months
ADRS with immunosuppressive drugs
Bone marrow suppression (dose related)
Lymphoma (4 fold increase)
pancreatitis
what infections can occur with immunosupressive drugs ? higher risk when on this and steroids
disseminated CMV, herpes zoster
pneumonia, viral hepatitis
Q fever
occurs w/o leukopenia
what will the immunosupressions inhibit the metabolism of
Sulfasalazine, mesalamine
Allopurinol
Aspirin
Furosemide
what drugs are an immunomodulator?
Methotrexate
tacrolimus
MOS of methotrexate
folic acid antagonist with anti-inflammatory effects
what does methotrexate reduce the need for?
steroid
what do you need to monitor with methotrexate?
LFTs
what category is methotrexate in pregnancy?
Category X
what is the most significant side effect of methotrexate?
Hepatic fibrosis
What is the MOA of cyclosporin?
inhibits production and release of IL-2 leads to inhibits activation of T-lymphocytes
what should you give while giving cyclosporin?
IV steroids
is cyclosporin alone able to maintain remission?
No, so you must switch over to AZA or 6-MP
Big ADRS with cyclosporin?
HTN
electrolyte abnormalities
kidney problems
MOA of tacrolimus
inhibits T-lymphocyte activation
when will the ADRs of tacrolimus go away
when you decrease the dose
Big ADRs of tacrolimus
Increased serum creatinine
Monoclonal antibody that binds to TNF-alpha
Inhibits inflammatory cytokines, inhibits leukocyte migration and activation of neutrophils
Infliximab
when is infliximab c/i?
NYHA class III/IV failure Hepatitis (will reactivate hep B)
what will your body develop against infliximab.
Antibodies. increased risk of infusion rx can lead to shorter duration of response
with most monoclonal antibodies there are higher rates of what?
TB with extrapulmonary involvement
what is a patient experiencing if they have these symptoms HA, dizziness, nausea, erythema at site, flushing, fever, chills, chest pain, cough, dyspnea, pruritis
Infusion rxn
when do delayed hypersensitivities develop to monoclonal antibodies?
3-13 days
how can you avoid delayed hypersensitivies w/ monoclonal antibodies
prednisone or methylprednisolone IV 30 minutes before
Toxicities w/ monocolonal antibodies
autoantibodies (lupus like)
malignancy and lymphomas
Only for crohn’s dz. recombinant fully-human immunoglobulin-1 anti-tumor necrosis factor (TNF)-alpha monoclonal antibody
adalimumab
what type injection if adalimumab?
SQ
what is the black box warning for Adalimumab ?
TB, invasive fungal and or other opportunistic infections
for crohn’s in pts with evidence of inflammation who have had inadequate response to, or are unable to tolerate conventional therapies. Patient must be in special program. originally for MS
Natalizumab
for crohn’s recombinant immunoglobulin-4 monoclonal antibody. infused
recombinant immunoglobulin-4 monoclonal antibody
Major adverse effect with natalizumab?
progressive multifocal encephalopathy
used for Failure to respond to sulfasalazine, tx of ileocolitis or colitis.
metronidazole
ADRs with metronidazole
GI upset, metallic taste, paresthesias, antabuse-like rxn
what 2 drugs together is recommended for fistula or abscess.
combination with standard tx
Metronidazole + Ciprofloxacin
what can provide symptomatic relief of diarrhea. MOA- inhibits excessive GI motility and propulsion.
opiates
which patients should you avoid opiates in?
Ulcerative colitis
what drug can cause hypertrichosis?
Cyclosporin
