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Pharm quarter 4 > Inflammatory Bowel Disease > Flashcards

Inflammatory Bowel Disease Flashcards

1
Q

Inflammatory bowel disease consists of what 2 problems?

A
  1. Ulcerative colitis which is a problem of mucosal inflammation, and is confined to the rectum and colon
  2. Chron’s disease- which is transmural inflammatory disease of the GI tract and can affect any part of the GI tract.
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2
Q

Look at slide 3 on page 1 of IBD lecture

A

DO IT!

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3
Q

Ulcerative colitis is one of the diseases under the heading of IBD which is characterized by diffuse inflammation of the mucasa. is the inflammation complete thickness or just limited to the mucosa?

A

Limited to the mucosa and affects only the distal colon and rectum extending proximally in a symmetrical, circumferential, and uninterrupted pattern.

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4
Q

What are the symptoms of Ulcerative colitis?

A

diarrhea and blood in stool, small and frequent bowel movements, colicky abdominal pain, rectal urgency, tenesmus, and incontinence. Severe cases present with fever, weight loss, and anorexia.

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5
Q

How is Ulcerative colitis diagnosed?

A

Stool examination and sigmoidoscopy, colonoscopy, and biopsy should all be performed to confirm colitis and rule out infectious disorder.- reveals mucosal changes consisting of loss of typical vascular pattern, granularity, friability, and ulceration. PANCA’s can also be seen but are not specific to UC as they are also seen in chrons

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6
Q

Describe mild UC?

A

4 or fewer stools per day with or without blood, no signs of systemic tox, and normal ESR, mild crampy symptoms

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7
Q

Describe Moderate UC?

A

> 4 stools per day of loose bloody stools, mild anemia, and non severe abdominal pain, animal signs of systemic toxicity (low grade fever), adequate nutrition usually maintained

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8
Q

Describe Severe UC?

A

Frequent loose bloody stools of greater than 6 a day with severe cramps and evidence of systemic toxicity

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9
Q

What are some of the acute complications that accompany UC?

A

Severe bleeding, Fulminant colitis and toxic megacolon, and perforations. some extra intestinal manifestations can exist such as arthritis, osteoporosis, ocular manifestations, erythema nodosum, and others….

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10
Q

what should the goals of therapy of UC be?

A

resolve acute inflammatory process
resolve complications (fistula, and abscesses
alleviate systemic manifestations
maintain remission

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11
Q

When treating UC what general factors are you looking at before treatment?

A
  1. location
  2. severity
  3. complications
  4. patient response
  5. therapy sequential-treat acute disease, maintain remission.
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12
Q

What are the differences in topical vs. systemic therapy for UC

A

Distal means you need to give topical therapy. Proximal means systemic therapy is needed.

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13
Q

What does fulminant inflammation mean when it comes to UC?

A

it means the patient has >10 stool/day, continuous bleeding requiring transfusion, toxicity, ab tenderness, and distention and colonic dilation.

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14
Q

What types of nonpharm treatment can help with UC?

A

The important thing to realize is that no diet improves or exacerbates UC. It does help however to reduce dietary fiber during exacerbation. Oral iron is helpful is anemia is suspected. Metamucil is also good for 1-2 times/day for mild diarrhea during remissions

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15
Q

what should the treatment be for mild to moderate distal UC.

A

Oral aminosalicylates, topical melamine or topical steroids.

  • topical mesalamine superior to topical steroids or oral aminosalicylates.
  • combination of oral and topical is superior to mono therapy
  • if refractory to oral aminosalizylates or topical steroids, may still respond to topical melamine.
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16
Q

How do you maintain remission in distal Ulcerative colitis?

A

Proctitis uses melamine suppositories. Distal colitis mesalamine enema. Oral amino salicylate or combo of oral and topical is better than mono therapy alone.
-Failure with both topical and oral requires use of thiopurines or infliximab may prove effective.

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17
Q

For mild to moderate extensive disease, what is the treatment recommended?

A

oral aminosalicylate such as sulfasalazine and mesalamine. -if refractory, oral steroids should be combined with topical
-if resistant to that, thiopurines or infliximab should be used.

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18
Q

How should remission be maintained for mild to moderate extensive disease?

A

oral aminosalicylates, thiopurines may be useful as steroid sparing agents if remission not maintained by oral aminosalicylates, infliximab if patients requirer for induction of remission.

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19
Q

In severe UC what are some of the treatments used to treat it?

A
  1. Non-refractory-oral prednisone, oral aminosalicylates and topical medications can be used.
  2. if refractory: infliximab if urgent hospitalization not required
  3. IV steroids if hospitalization is required
  4. Failure to respond to these within 5 days indicates need for colectomy or treatment with cyclosporine
  5. once in remission-it is enhanced by addition of 6-mp as well as infliximab for avoiding colectomy.
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20
Q

Specifically what medications should be used in severe UC?

A

Sulfasalazine or mesalamine + prednisone

  • Remision should taper prednisone then reduce sulfasalazine or mesalamine after 1-2 months to approximately half.
  • if refractory- add azathioprine or mercaptopurine(6-MP) or consider infliximab if no response.
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21
Q

When a person has fulminant UC what is the treatment recommendation?

A

Hydrocortisone(broad spectrum abx)

  • if in remission-change to prednisone add sulfasalazine or mesalamine
  • if refractory after 5-7 days- give cyclosporine IV, TNF alpha blocker, monoclonal antibodies, if no response, Colectomy is the last option.
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22
Q

When would surgical resection be the option for treatment of UC?

A
  1. if the patient had high grade dysplasia that was suspect of cancer
  2. its with severe disease requiring high dose steroids that can’t be tapered after 6 to 12 months would need a colectomy.
  3. Exsanguinating hemorrhage, perforation would also qualify pt. for treatment.
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23
Q

Maintenance of UC would be done with what medications?

A

Aminosalicylates (sulfasalazine and mesalamine) or AZAor 6MP (mercaptopurine)
-alternative therapy would be use of infliximab

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24
Q

What is churn’s disease?

A

This is the other for of IBD that can affect any segment of the GI from the mouth to the anus and has inflammation that occurs throughout the full thickness of the bowel wall, and is know for its skip pattern of involvement, strictures, fistulas, and ulcers.

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25
Q

What are some of the symptoms of chrohn’s disease?

A

Diarrhea and Abdominal pain are the key features. Fever, perianal discomfort, bleeding, and arthralgia can also occur and are common complaints among those affected.

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26
Q

What are some extra intestinal manifestations of Chron’s disease?

A

arthralgia/arthritis (25%), skin manifestations, ocular manifestations.

27
Q

What are some of the common infectious etiologies of Chronhs disease?

A

Viruses, bacteria, mycobacteria, chlamydia in the GI tracts

28
Q

What are some of the common genetic etiologies of Chrons?

A

1st degree relatives have 4-20 percent risk of IBD. Metabolic defects can also be responsible. Connective tissue disorders are also common etiologies.

29
Q

what are some common environment etiologies of Chron’s diseasse

A

Diet and smoking play a huge part of Chron’s development.

30
Q

Immunity can play a part in the etiology of Chrons’. how?

A

altered host susceptibility as well as immune mediated mucosal damage can cause chron’s.

31
Q

lastly, How does physiology play a role in Chron development.

A
  • stress may have some part to do with it. Emotional and physical trauma, the same that can lead to ulcers, can cause it. Occupational exposure can also cause its development.
32
Q

Of the infectious factors, What would one see in a person with Chron’s if infectious in etiology?

A
  1. one would maybe see an increase in pathogenic bacteria such as Bactericides would be present, E. coli
  2. Decreased beneficial bacteria such as bifidobacterium and lactobacillus would also be seen.
33
Q

What is one key factor of CD its vs. Non CD pts.?

A

CD patient generally have an impaired immune response due to decreased blood flow to affected site or decreased neutrophil and IL-8 accumulation at injury sites.

34
Q

What are some environmental factors of Chron’s?

A

Luminal bacteria develops aberrant immune response to enteric flora.
Dietary antigens contribute inflammation
Protective for UC although there is a negative correlation.
More aggressive disease in CD if smoking.

35
Q

Some non pharm management of Chron’s would be?

A

Psychological support, Fiber limitation if cramping and diarrhea, Decrease Fat intake when steatorrhea is present. Multivitamin with minerals daily.

36
Q

Treatment of Crohn’s is based on…

A

Location and Severity as well as extra intestinal manifestations

37
Q

What is the process of Treatment with drugs for mild to moderate Chron’s (if pt is ambulating and tolerating oral intake?

A

1st therapy would be salicylate therapy.
-if effective-mesalamine is the next step for maintenance
-if failed treatment-metronidazole or ciprofloxacin would be used and if effective, maintained with Mesalamine.
If completely refractory to mild to moderate tx treat as moderate to severe and step up treatment.
-if effective but remission is not maintained, consider immumnosuppresives

38
Q

What is the process of treatment of chron’s treatment if moderate to severe meaning weight loss, abdominal pain and vomitting are present?

A

Oral prednisone with rapid taper would be the 1st step. based on whether or not this is effective..

  • yes-consider immunosuppressants with prednisone being tapered. continue therapy if effective.
  • if not effective, infliximab must be used
  • effective initially but immunosuppressive is not working, consider methotrexate.
39
Q

What is the process of treatment of chron’s treatment if severe meaning the patient has a high fever, guarding, or intractable vomiting?

A

IV steroids with rapid taper would be the first step. if this was ineffective use infliximab.
-if effective conducer use of immunosuppressant for chronic use to maintain remission. If this is unsuccessful in remission maintenance, consider methotrexate.

40
Q

For mild to moderate Crohn’s disease which oral aminosalicylate is better for maintenance of remission?

A

Mesalamine tends to maintain remission of CD better than sulfasalazine.

41
Q

If antibiotics are required which abs should be used for mild to moderate CD and do they show problems?

A

Metronidazole has shown long term benefit but long term use can cause peripheral neuropathy. Thus ciprofloxacin should be used if abs is needed.

42
Q

Specifically, lets say the CD is in the Ileocolonic or colonic region of the GI tract. What would recommended 1st step therapy be?

A

Oral mesalamine would be 1st choice, with sulfasalazine as a ready 2nd choice.

43
Q

What if the CD was in the perianal region? what would pharmacologic treatment call for?

A

Oral mesalamine would again be 1st choice, with sulfasalazine as a ready 2nd choice. Metronidazole would be used for treatment if salicylate (mesalamine or sulfasalazine) treatment was ineffective.

44
Q

What if the Mild- moderate CD was in the small bowel? what would treatment require then?

A

Oral mesalamine 1st choice with metronidazole if salycilate therapy was ineffective.

45
Q

Now we are on to Moderate to severe Crohn’s which would mean that there was moderate to severe weight loss, continual abdominal pain, and vomiting present.

A

this is the same protocol as mild to moderate but budesonide and oral prednisone is added. If refractory or fistulizeing disease add inflixamab, once the pt responds to therapy, prednisone should be tapered and AZA, 6-MP or MTX

46
Q

With sever-fulminant crown’s, What is the course of care?

A

hospitalization, surgical intervention and supportive care are usually done. Parenteral corticosteroids are also started as fellas IV cyclosporin, tacrolimus, and infliximab are all options.

47
Q

To maintain CD you cannot use long term corticosteroids. What are some options for Maintaining treatment?

A

Azathioprine or 6-MP are usually 1st line for maintenance.

  • this treatment or mesalamine can also be effective after surgical resection to prevent recurrence.
  • Infliximab for every 6 weeks then every 8 weeks or methotrexate up to 16 weeks followed by lower IM dose weekly.
48
Q

Aminosalycilates used in CD that are oral use are?

A

Sulfasalazine, olsalazine, mesalazine

49
Q

Aminosalycilates used in CD that are topical are?

A

Mesalamine

50
Q

Corticosteroids used in CD that are oral are?

A

Prednisone

51
Q

Corticosteroids used in CD that are topical are?

A

hydrocortisone.

52
Q

Immunomodulators or thiopurines used in CD are?

A

Azathioprine or 6-MP

53
Q

Monoclonal antibodies used in CD are?

A

infliximab, adalimab, natalizumab, vedolizumab

54
Q

Other drugs not in category used in cd are?

A

MTX(methotrexate), cyclosporin, abx.

55
Q

Aminosalycilates used in CD such as sulfasalazine, olsalazine, mesalazine are mainly used for?

A

inducing and maintaining remission. but they can take 2-3 weeks to respond.

56
Q

Sulfasalazine specifically is metabolized by intestinal bacteria to 5-ASA and Sulfapyridine. Why could you not give this drug to a pt?

A

You could not give this drug to a pt if he had Salicylate hypersensitivity or renal impairment.

57
Q

Side effects of sulfasalazine are not well tolerated. What are some of these?

A

N/V, Heartburn, Anorexia, HA. You cannot use this drug in its with Sulfa allergy. this drug can also cause blood disorders, impair folic acid absorption ( thus folic acid must be co prescribed), can be related to low sperm counts, and can cause idiosyncratic reactions such as hepatocellular injury, agranulocytosis, and lupus like phenomena. OVERALL, take mesalamine, due to less side effects.

58
Q

Mesalamine is also an amino salycilate but is not the same as sulfasalazine. What is the MOA of of mesalamine?

A

To be honest, no one really knows. Targets different parts of the colon with different formulations. Slow response with ARS of Local itching mild rectal irritation with topical enemas. Idiosyncratic runs, pleuropericardidties, pancreatitis, nephrotic syndrome.

59
Q

Corticosteroids are the next step up for pts. that aminosalicylates are not working on. How do they work and what route do they come in?

A

Mainly, the MOA of these drugs is to perform antiinflamitory affects which improves symptoms and improves the disease severity. They are available in PO and IV doses Topical is also available.

60
Q

what are some of the portico steroids.

A

prednisone, prednisolone, hydrocortisone, methyprednisolone, budesonide.

61
Q

What do you do when you don’t want patients on long term steroids?

A

Tapering is the best way to go with these. Inability to taper is a good indication for the next step which is an antimetabolite and or inflixamab therapy.

62
Q

when should parenteral therapy be considered?

A

this therapy is indicated in its falling to respond to 7-14 days of high dose oral prednisone or equivalent.

63
Q

what are some complications for overuse of Oral corticosteroids?

A

Glucose intolerance/metabolite abnormalities, hyperkalemia, hyponatremia, Glucose absorption problems

  1. Adrenal insufficiency and infection causing N/V and postural hypotension
  2. long term therapy >3 mo can cause osteoporosis.

Pharm quarter 4 (2 decks)

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