Inflammatory Bowel Disease - Therapy Flashcards
aims of therapy
control inflammation and heal mucosa
restore normal bowel habit
improve quality of life
balance the effects of disease with side effects of treatment
avoid long-term complications
be a good advocate for the patient
therapeutic strategies
lifestyle advice
drugs
surgery
lifestyle advice
smoking aggravates Crohns - worse disease outcome, more rapid recurrence post-surgery
diet not implicated in pathogenesis but can influence symptoms
drug therapy
anti-inflammatory effects
ULCERATIVE COLITIS 5 ASA (mesalazine) steroids immunosuppressants anti-TNF therapy
CROHNS DISEASE
steroids
immunosuppressants
anti-TNF therapy
5 ASA
topical effect
anti-inflammatory properties
reduces risk of colon cancer
side effects
diarrhoea, idiosyncratic nephritis
types of 5 ASA
ORAL
prodrugs
pH dependent release
delayed release
TOPICAL
suppositories
enemas
5-ASA drugs in use
sulphasalazine balsalazide mezavant mesalazine pH release - asacol delayed release - pentasa
pentasa
released: duodenum jejunum ileum colon
asacol salofalk
released:
ileum
colon
balsalazide
released:
colon
salazopyrin
released:
colon
suppositories vs enemas
mucosal adherence = better in suppositories
reflex contraction aids proximal spread of foam or liquid enemas
corticosteroids
systemic anti-inflammatory properties
PREDNISOLONE
to induce remission
short course - high does initially, reducing over 6-8 weeks
risk of steroid dependency
steroid side effects
MUSCULOSKELETAL
avascualr necrosis
osteoporosis
GASTROINTESTINAL
CUTANEOUS
acne
thinning of skin
METABOLIC
weight gain
diabetes
hypertension
NEUROPSYCHIATRIC
CATARACTS
GROWTH FAILURE
immunosuppression
when more potent suppression of inflammation required
use of immunosuppression
UC
steroid-sparing agents
CROHNS
maintenance therapy
azathioprine/mercaptopurine
methotrexate - strong
azathioprine
slow onset of action (16 weeks)
TPMT activity contributes to toxicity
avoid co-prescription of allopurinol
regular blood monitoring required
azathioprine side effects
pancreatitis
leucopenia
hepatitis
small risk of lymphoma, skin cancer
anti-TNF therapy
TNF = pro inflammatory cytokine
antibodies to TNF
chimeric (infliximab; IV infusion)
humanised (adalimumab; S/C injection)
promote apoptosis of activated T-lymphocytes
rapid onset of action
use of anti-TNF alpha therapy
as part of long term strategy including immune suppression, surgery, supportive therapy
refractory, fistulising disease
exclude current infection/TB
SURGERY in IBD
emergency
failure to respond to medical therapy, small bowel obstruction, abscess, fistulae
elective
failure to respond to medical therapy
dysplasia of colon mucosa
surgery for Crohns
minimise the amount of bowel resected
not curative
repeated resection of small intestine can result in ‘small gut syndrome’ and requirement of lifelong total parenteral nutrition
surgery for UC
curative
option of permanent ileostomy or restorative proctocoloectomy and pouch
