Inflammatory Bowel Disease (IBD) Flashcards
Goals of therapy
- Resolve acute inflammatory process
- Resolve complications
- Alleviate systemic manifestations
- Maintain remission
General Considerations
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
IBD Severity Definitions
1) Clinical remission
2) Mild disease
3) Moderate-severe disease
4) Severe-fulminant disease
Clinical Remission
- Patient is asymptomatic
- No inflammation
- Can be spontaneous or due to medical intervention
Mild disease
- Patient is ambulatory
- Tolerating oral diet
- Weight loss of < 10%
- Stool with out blood
Moderate-Severe
- Failed treatment
- Fever, weight loss, abdominal pain, nausea, vomiting, etc.
- Stools may be bloody >4 per day
Severe-fulminant
- 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
Drugs to Avoid in IBD
1) Antidiarrheal (loperamide, diphenoxylate/atropine, codeine) can lead to toxic megacolon
2) NSAIDs can worsen symptoms
3) Opioids- reduce GI motility
Non-pharmacological treatment
- High fiber diet
- Physical activity
Treatment of mild to moderate
-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
Treatment of moderate to severe
- 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
Treatment for severe to fulminant
- IV hydrocortisone 100mg q6to 8h
- If no response in 7 days, IV cyclosporine 4mg/kg/day
How to tapper off during remission of mild to moderate IBD
- Maintain the same meds but cut the dose in half
- If on enema increase time between administrations
How to tapper off during remission of Moderate to severe IBD
- Taper prednisone
- Then reduce sulfasalazine or mesalamine after 1 to 2 months to half of the original dose
How to tapper off during remission of severe to fulminant
- Change to prednisone
- Add sulfasalazine or mesalamine
- Steroid should be withdrawn 1 to 2 months later
- Add on sulfasalazine to maintain remission
Aminosalicylates
- Sulfasalazine (4 to 6g/day)
- Mesalamine (3 to 4g/day)
- Unclear antiinflammatory effects
Sulfasalazine
- Unclear antiinflammatory effects
- Do not give to patients with sulfa allergy
- May also cause GI distress
Mesalamine
- Unclear antiinflammatory effects
- Is associated with “ghost tablet”
- Let patient know so that they don’t freak out
Azathioprine
-Main concern is chronic immunosuppression
Methotrexate
- Pregnancy category X
- Should supplement patients with folate
Monoclonal antibodies (MAb)
- Test for HBV and TB prior to use
- Make sure all immunizations are up to date
- Don’t use in pts with heart failure
Natalizumab (Tysarbi)
-Patient must be enrolled in the (CD-TOUCH) because of risk for multifocal encephalopathy
