Inflammatory Bowel Disease - Therapy

Question 1

aims of therapy

Answer 1

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

Question 2

therapeutic strategies

Answer 2

lifestyle advice
drugs
surgery

Question 3

lifestyle advice

Answer 3

smoking aggravates Crohns - worse disease outcome, more rapid recurrence post-surgery

diet not implicated in pathogenesis but can influence symptoms

Question 4

drug therapy

Answer 4

anti-inflammatory effects

ULCERATIVE COLITIS
5 ASA (mesalazine)
steroids
immunosuppressants
anti-TNF therapy

CROHNS DISEASE
steroids
immunosuppressants
anti-TNF therapy

Question 5

5 ASA

Answer 5

topical effect
anti-inflammatory properties
reduces risk of colon cancer

side effects
diarrhoea, idiosyncratic nephritis

Question 6

types of 5 ASA

Answer 6

ORAL
prodrugs
pH dependent release
delayed release

TOPICAL
suppositories
enemas

Question 7

5-ASA drugs in use

Answer 7

sulphasalazine
balsalazide
mezavant
mesalazine
pH release - asacol
delayed release - pentasa

Question 8

pentasa

Answer 8

released:
duodenum
jejunum
ileum
colon

Question 9

asacol salofalk

Answer 9

released:
ileum
colon

Question 10

balsalazide

Answer 10

released:

colon

Question 11

salazopyrin

Answer 11

released:

colon

Question 12

suppositories vs enemas

Answer 12

mucosal adherence = better in suppositories

reflex contraction aids proximal spread of foam or liquid enemas

Question 13

corticosteroids

Answer 13

systemic anti-inflammatory properties

PREDNISOLONE

to induce remission
short course - high does initially, reducing over 6-8 weeks

risk of steroid dependency

Question 14

steroid side effects

Answer 14

MUSCULOSKELETAL
avascualr necrosis
osteoporosis

GASTROINTESTINAL

CUTANEOUS
acne
thinning of skin

METABOLIC
weight gain
diabetes
hypertension

NEUROPSYCHIATRIC

CATARACTS

GROWTH FAILURE

Question 15

immunosuppression

Answer 15

when more potent suppression of inflammation required

Question 16

use of immunosuppression

Answer 16

UC
steroid-sparing agents

CROHNS
maintenance therapy

azathioprine/mercaptopurine
methotrexate - strong

Question 17

azathioprine

Answer 17

slow onset of action (16 weeks)
TPMT activity contributes to toxicity

avoid co-prescription of allopurinol

regular blood monitoring required

Question 18

azathioprine side effects

Answer 18

pancreatitis
leucopenia
hepatitis
small risk of lymphoma, skin cancer

Question 19

anti-TNF therapy

Answer 19

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

Question 20

use of anti-TNF alpha therapy

Answer 20

as part of long term strategy including immune suppression, surgery, supportive therapy

refractory, fistulising disease

exclude current infection/TB

Question 21

SURGERY in IBD

Answer 21

emergency
failure to respond to medical therapy, small bowel obstruction, abscess, fistulae

elective
failure to respond to medical therapy
dysplasia of colon mucosa

Question 22

surgery for Crohns

Answer 22

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

Question 23

surgery for UC

Answer 23

curative

option of permanent ileostomy or restorative proctocoloectomy and pouch