Inflammatory Bowel Disease (IBD)

Question 1

Clinical Remission

Answer 1

• Patient is asymptomatic

- Can occur on its own, or with medical intervention

Question 2

Mild IBD

Answer 2

• Patient is ambulatory
• Tolerating oral diet
• < 10% loss in weight
• No symptoms of systemic disease
• No blood in stool

Question 3

Moderate to Sever IBD

Answer 3

• Failed treatment
• Symptoms of systemic fever
• Stools may be bloody (> 4 times/day)

Question 4

Severe to Fulminant IBD

Answer 4

• Persistent symptoms despite steroid or biologic
• In hospital with high fever
• Blood in stools (> 6 times/day)

Question 5

Drugs to avoid in IBD

Answer 5

• Antidiarrheal meds (Loperamide, atropine, codeine, diphenoxylate)
• NSAIDs: can worsen GI symptoms
• Opioids: reduce GI motility

Question 6

Non-pharmacological treatment of IBD

Answer 6

• High fiber diet

- Routine physical activity

Question 7

Treatment Mild to Moderate IBD

Answer 7

-Oral sulfasalazine (4-6g/day)
or Oral mesalamine (3-4g/day)
a) Ulcerative Colitis (UC)-Distal disease; use mesalamine, enema, or suppository
or corticosteroid suppository
b) Crohn’s Disease (CD)-If only in the small bowel or perianal disease Metronidazole (Flagyl) 10 to 20mg/kg/day

Question 8

Treatment for Moderate to Severe IBD

Answer 8

• Oral sulfasalazine or mesalamine PLUS prednisone (40-60mg/day)
  a) UC Inadequate response: add azathioprine, mercaptopurine or infliximab
  b) CD Refactory and fistulizing disease: add infliximab
• If inadequate response; add adalimumab, natalizumab, or certolizumab

Question 9

Treatment for Severe to Fulminant IBD

Answer 9

• IV hydrocortisone 100mg q6-8h

- If no response in 7 days; use IV cyclosporine 4mg/kg/day

Question 10

Remission in Mild to Moderate IBD

Answer 10

• Keep the same medications, but reduce the dose by 50%

- If enema or suppository used; reduce dosing frequency

Question 11

Remission in Moderate to Severe IBD

Answer 11

• Taper prednisone

- Then reduce sulfasalazine or mesalamine after 1-2 months to 50% of the original dose

Question 12

Remission in Fulminant IBD

Answer 12

• Change IV hydrocortisone to oral prednisone
• Add sulfasalazine or mesalamine
• Steroid should be withdrawn after 1-2 months and remission maintained with sulfasalazine

Question 13

Sulfasalazine

Answer 13

• Unclear anti-inflammatory effects

- Contraindicated in patients with a sulfa allergy

Question 14

Mesalamine

Answer 14

• Unclear anti-inflammatory effects

- “ghost” tablet may be found in patient’s stool

Question 15

Azathioprine and Mercaptopurine

Answer 15

• Main concern is chronic immunosuppression
• Patients with TPMY deficiency are at increased risk of myelosuppression and may need lower doses
• Can cause sever nausea, vomiting, diarrhea, rash, increase in AST/ALT

Question 16

Methotrexate

Answer 16

• Effective in inducing remission in patients on steroids in Crohns
• Pregnancy category X: d/c this med 3 months before becoming pregnant (if possible)

Question 17

Monoclonal Antibodies

Answer 17

• Test for HBV and TB
• Confirm that vaccines are up to date
• DO NOT use in patient’s with NYHA class 3 or 4/HF
• Autoantibodies may develop if patients do not receive regularly scheduled therapy

Question 18

Vedolizumab (Entyvio)

Answer 18

• MAb

- Avoid live vaccines while using this drug

Question 19

Natalizumab (Tysarbi)

Answer 19

• Patient must enroll in CD-TOUCH program because of risk for multifocal encephalopathy
• DO NOT use with other immunosuppressant drugs

Question 20

Prednisone or Budesonide (Entocort)

Answer 20

• Budesonide: less systemic effects
• Hydrocortisone enema or foam for rectal use
• Use >2 weeks; requires 3-4 weeks to taper
• Short term side effects; weight gain, fluid retention, mood swings, GI upset, increased BP/Blood glucose
• Long term side effects; Adrenal suppression, cushion’s syndrome, immunosuppression, hypertension, hyperglycemia, osteoporosis, cataracts

Question 21

Probiotics?

Answer 21

-There are conflicting data whether probiotics are effective or not in treating IBD