Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis)

Question 1

Which drugs are used in chronic bowel disorders?

Answer 1

Sulfasalazine, sulfapyridine, mesalazine, balsalazide sodium, olsalazine sodium, MTX (w/ folic acid), monoclonal antibodies targeting TNF-alpha.

Question 2

What are two common side effects of 5-aminosalicylic acid (5ASA) drugs?

Answer 2

Blood disorders and lupus-like syndrome.

Question 3

Which cytokine modulating monoclonal antibodies can be used to treat inflammatory bowel diseases?

Answer 3

Infliximab, adalimumab, golimumab.

Question 4

What type of disease is Crohn’s disease?

Answer 4

Chronic, inflammatory bowel disease.

Question 5

What are the key features of Crohn’s disease?

Answer 5

Thickened areas of the GIT wall. Inflammation extending through all layers. Deep ulceration and fissuring of the mucosa. Presence of granulomas. Affected areas may be found anywhere in the GIT.

Question 6

What are the symptoms of Crohn’s disease?

Answer 6

Abdominal pain. Diarrhoea. Fever. Weight loss. Rectal bleeding.

Question 7

What complications are associated with Crohn’s disease?

Answer 7

Intestinal strictures (narrowing of the intestine). Abscesses in the GIT wall or surrounding structures. Fistulae. Anaemia. Malnutrition. Colorectal and small bowel Cx. Growth failure. Delayed puberty in children.

Question 8

What extra-intestinal manifestations are associated with Crohn’s disease?

Answer 8

Extra-intestinal manifestations include arthritis and other abnormalities of the joints, eyes, liver, and skin.

Question 9

In what proportion of patients with Crohn’s disease does fistulising Crohn’s disease occur?

Answer 9

1/4.

Question 10

What are the aims of Crohn’s disease treatment?

Answer 10

Induction and maintenance of remission. Reducing symptoms and maintaining or improving quality of life, whilst reducing toxicity in both the short and long term. In fistulising Crohn’s Disease, surgery and medical treatment aim to close and maintain closure of the fistula.

Question 11

What drugs are used for first line for monotherapy in acute Crohn’s disease?

Answer 11

Corticosteroids (prednisolone, methylprednisolone, and IV hydrocortisone).

Question 12

When is budesonide considered for use as monotherapy in acute Crohn’s disease?

Answer 12

In distal ileal, ileocecal or right sided colonic disease, where conventional corticosteroids are contraindicated or unsuitable.

Question 13

When should budesonide not be considered for monotherapy in acute Crohn’s disease?

Answer 13

In severe presentations or exacerbations.

Question 14

When are aminosalicylates considered as monotherapy in acute Crohn’s disease?

Answer 14

In patients for whom corticosteroids are contraindicated or otherwise inappropriate.

Question 15

When should aminosalicylates not be considered for monotherapy in acute Crohn’s disease?

Answer 15

In severe presentations or exacerbations.

Question 16

When should add on therapy be considered for acute Crohn’s disease?

Answer 16

Add on treatment is prescribed if there are two or more inflammatory exacerbations in 12 months, or the corticosteroid dose cannot be reduced.

Question 17

Which medications can be added to corticosteroid treatment to induce remission?

Answer 17

Azathioprine or mercaptopurine (unlicensed).

Question 18

If azathioprine or mercaptopurine add-on treatment is not suitable for a Crohn’s patient, what can be used as an alternative?

Answer 18

Methotrexate.

Question 19

Which TNF-alpha inhibiting monoclonal antibodies can be considered, under specialist supervision, for severe active Crohn’s disease?

Answer 19

Adalimumab or infliximab.

Question 20

When would TNF-alpha inhibitors be considered in acute Crohn’s disease?

Answer 20

Following inadequate response to conventional treatment or contraindications.

Question 21

Which monoclonal antibodies can be considered in place of adalimumab or infliximab when treatment with these drugs fails, is contraindicated, or not tolerated for the induction of remission in patients in Crohn’s disease?

Answer 21

Vedolizumab or ustekinumab.

Question 22

Which symptoms of relapse should Crohn’s patients, who refuse treatment for maintenance of remission, be made aware of?

Answer 22

Unintended weight loss, abdominal pain, diarrhoea, general ill-health.

Question 23

What should be put in place when a Crohn’s patient refuses treatment for maintenance of remission?

Answer 23

A suitable follow up plan should be agreed upon and information on access to healthcare should be provided in the case of relapse.

Question 24

When used with corticosteroids to induce remission in patients with Crohn’s disease, which drugs can be used to maintain remission?

Answer 24

Azathioprine or mercaptopurine.

Question 25

When can azathioprine or mercaptopurine be considered to maintain remission in patients with Crohn’s disease who have not received these drugs for induction of remission?

Answer 25

Particularly in those with factors such as early age of onset, perianal disease, corticosteroid use at presentation, severe presentations.

Question 26

When can methotrexate be considered for maintenance of remission in patients with Crohn’s disease?

Answer 26

When it has been used to induce remission or treatment with azathioprine or mercaptopurine has failed, is not tolerated, or is contraindicated.

Question 27

Which drugs should not be used to maintain remission in patients with Crohn’s disease?

Answer 27

Corticosteroids or budesonide.

Question 28

What feature distinguishes Crohn’s disease and ulcerative colitis?

Answer 28

Crohn’s affects any part of the GIT and UC affects the colon only.

Question 29

Give some examples of aminosalicylates.

Answer 29

Sulfasalazine, mesalazine, balsalazide, olsalazine.

Question 30

What key side effect(s) should patient on aminosalicylates be aware of?

Answer 30

Blood disorders. Unexplained bleeding, bruising, purpura, sore throat, fever or malaise occurring during treatment. A blood count should be performed and drug stopped immediately if there is signs of blood dyscrasias.