Inflammatory Bowel Disease (IBD)

Question 1

Goals of therapy

Answer 1

• Resolve acute inflammatory process
• Resolve complications
• Alleviate systemic manifestations
• Maintain remission

Question 2

General Considerations

Answer 2

1) Location (systemic or local therapy)
2) Therapy should be sequential (treat acute disease then maintain remission)
3) Risk vs Benefit of therapy- immunosuppression may reduce IBD but put patient at risk for other things

Question 3

IBD Severity Definitions

Answer 3

1) Clinical remission
2) Mild disease
3) Moderate-severe disease
4) Severe-fulminant disease

Question 4

Clinical Remission

Answer 4

• Patient is asymptomatic
• No inflammation
• Can be spontaneous or due to medical intervention

Question 5

Mild disease

Answer 5

• Patient is ambulatory
• Tolerating oral diet
• Weight loss of < 10%
• Stool with out blood

Question 6

Moderate-Severe

Answer 6

• Failed treatment
• Fever, weight loss, abdominal pain, nausea, vomiting, etc.
• Stools may be bloody >4 per day

Question 7

Severe-fulminant

Answer 7

• Persistent symptoms despite steroid or biologic therapy
• High fever, persistent vomiting
• Lots of weight loss, evidence of abscess
• Stools are frequent, loose, and bloody >6x per day

Question 8

Drugs to Avoid in IBD

Answer 8

1) Antidiarrheal (loperamide, diphenoxylate/atropine, codeine) can lead to toxic megacolon
2) NSAIDs can worsen symptoms
3) Opioids- reduce GI motility

Question 9

Non-pharmacological treatment

Answer 9

• High fiber diet

- Physical activity

Question 10

Treatment of mild to moderate

Answer 10

-Oral sulfasalazine 4 to 6g/day
or Oral mesalamine 3 to 4g/day
-If distal: Mesalamine enema/suppository, or corticosteroid enema
-Metronidazole (Flagyl) 10 to 20mg/kg/day if disease is only in small bowel or perianal disease

Question 11

Treatment of moderate to severe

Answer 11

• Oral sulfasalazine 4 to 6g/day or Oral mesalamine 3 to 4g/ day PLUS prednisone
• If inadequate response add; azathioprine, mercaptopurine or infliximab
• If refractory and fistulizing disease add infliximab
• If inadequate response add adalimumab, or other MAb

Question 12

Treatment for severe to fulminant

Answer 12

• IV hydrocortisone 100mg q6to 8h

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

Question 13

How to tapper off during remission of mild to moderate IBD

Answer 13

• Maintain the same meds but cut the dose in half

- If on enema increase time between administrations

Question 14

How to tapper off during remission of Moderate to severe IBD

Answer 14

• Taper prednisone

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

Question 15

How to tapper off during remission of severe to fulminant

Answer 15

• Change to prednisone
• Add sulfasalazine or mesalamine
• Steroid should be withdrawn 1 to 2 months later
• Add on sulfasalazine to maintain remission

Question 16

Aminosalicylates

Answer 16

• Sulfasalazine (4 to 6g/day)
• Mesalamine (3 to 4g/day)
• Unclear antiinflammatory effects

Question 17

Sulfasalazine

Answer 17

• Unclear antiinflammatory effects
• Do not give to patients with sulfa allergy
• May also cause GI distress

Question 18

Mesalamine

Answer 18

• Unclear antiinflammatory effects
• Is associated with “ghost tablet”
• Let patient know so that they don’t freak out

Question 19

Azathioprine

Answer 19

-Main concern is chronic immunosuppression

Question 20

Methotrexate

Answer 20

• Pregnancy category X

- Should supplement patients with folate

Question 21

Monoclonal antibodies (MAb)

Answer 21

• Test for HBV and TB prior to use
• Make sure all immunizations are up to date
• Don’t use in pts with heart failure

Question 22

Natalizumab (Tysarbi)

Answer 22

-Patient must be enrolled in the (CD-TOUCH) because of risk for multifocal encephalopathy