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PHRM 864 - EXAM 4 > Inflammatory bowel diseases > Flashcards

Inflammatory bowel diseases Flashcards

1
Q

What is ulcerative colitis

A

Mucosal inflammation confined to rectum and colon

Lower GI inflammation that affects mucosal and submucosal layers (superficial)
causes Hemorrhoids, anal fissures, and perirectal abscesses, Toxic megacolon (life threatening), Massive colonic hemorrhage, and colonic stricture

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2
Q

What is Crohn’s Disease

A

Transmural inflammation of GI tract that can affect any part from the mouth to the anus
Transmural inflammation causing deep elongated ulcers
Causes weight loss, growth failure, deficiencies, hypokalemia, and hypoalbuminemia

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3
Q

What drugs can cause IBD

A

NSAIDS - best to avoid in patients with IBD
Antibiotics - Unclear how it can cause IBD but potential association

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4
Q

Goals of therapy

A

resolve acute inflammation
resolve and prevent complications
alleviate extraintestinal manifestations
avoid need for surgical palliation
maintain QOL

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5
Q

Nonpharmacologic therapy

A

adress nutritional deficiencies, impaired absorption
Probiotic therapy
Surgery

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6
Q

ASA Agents

A

Sulfasalazine - active ingredient is mesalamine and it will stay in the lumen and be excreted through the stool

Mesalamine - can be administered alone and is rapidly absorbed in small intestine but not the colon

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7
Q

Topical (enemas) Mesalamine

A

Used for left sided disease

Topical is more effective than oral but can give patient topical and oral mesalamine as combo therapy

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8
Q

Suppository mesalamine

A

Used for proctitis

Topical is more effective than oral but can give patient topical and oral mesalamine as combo therapy

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9
Q

Oral Mesalamine

A

Apriso - Released in the colon
Lialda - released in the terminal ileum
Pentasa - Duodenum Ileum
Asacol HD and Delzicol - Terminal ileum
Olsalazine - Colon
Balsalazide - Colon

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10
Q

ASA ADRs - Sulfasalazine

A

Nausea, vomiting, headaches, anorexia, rash

Monitor CBC, LFTs, BUN/Scr

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11
Q

ASA ADRs - Mesalamine

A

BETTER TOLERATED
Nausea, vomiting, headaches, diarrhea, rash, pruritus

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12
Q

Corticosteroids

A

Anti-inflammatory

Rectal Hydrocortisone
Suppositories - (Proctocort, Hemril), foam (cortifoam), Enema (Cortenema, colocort)

Budesonide - Oral

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13
Q

Budesonide

A

Enterocort - Enterocort EC

Uceris - pH sensitive

Drug interaction CYP3A inhibitors: these inhibit first pass metabolism and cause more side effects of budesonide

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14
Q

Systemic corticosteroids

A

Oral prednisone
IV methylprednisolone or hydrocortisone

May be used for disease flares/induction of remission

ADRs: Give calcium and vitamin D supplements while on steroids, May consider bisphosphonate tx in patients with risk of osteoporosis and patients using for > 3 months

Acute ADRs: Hyperglycemia, gastritis, mood changes, elevated BP

Long ADRs: aseptic necrosis, cataracts, obesity, growth failure, HPA suppression, osteoporosis

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15
Q

Azathioprine (AZA) and Mercaptopurine (6-MP) - use, ADRs, monitoring

A

Can be effective in Long term Txt of UC and CD
Reserved for patients who failed 5-ASA tx or patients who are refractory to/dependent on steroids

ADRs: GI: N/V/D, Anorexia, stomatitis
Hematologic: bone marrow suppression
Hepatic: hepatotoxicity
Idiosyncratic: fever, rash, arthralgia, pancreatitis

Monitoring: TPMT (enzyme needed to metabolize thiourine and can worsen side effects if patient has genetic disorder), CBC, and LFTs, (all at baseline and CBC and LFTs q week for fist month, q 1-2 weeks after a dose change, and q 1-3 months thereafter

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16
Q

Cyclosporine

A

effective inducing remission in patients with refractory UC

Not a long term option - first IV infusion then PO

ADRs: nephrotoxicity, neurotoxicity, metabolic (HTn, Hyperlipidemia, hyperglycemia) GI upset, gingival hyperplasia, hirsutism

Monitor: BP (q visit), BUN/SCr (q 2 weeks), LFTs (q 2 weeks) all at baseline as well

Drug interaction with CYP3A and P-glycoprotein

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17
Q

Methotrexate

A

Can be used in CD
assist in inducing remission

ADRs: Bone marrow supression, N/V, stomatitis, mucositis, cirrhosis, hepatitis, fibrosis, hypersensitivity pneumonitis, rash, urticaria, alopecia

Contraindications: Prego, pleural effusion, chronic liver disease, immunodeficiency, Preexisting blood dyscrasias

Monitoring: CXR, CBC, SCr, LFTs - baseline and q4-8 weeks

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18
Q

Anti- TNF agents used for UC and CD

A

Infliximab (remicade)
Adalimumab (humira)

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19
Q

Anti- TNF agent used for UC ONLY

A

Golimumab (simponi)

20
Q

Anti- TNF agent used for CD ONLY

A

Certolizumab pegol (cimzia)

21
Q

Anti-Integrin agent for CD

A

Natalizumab (tysabri)

22
Q

Anti-integrin agent for UC and CD

A

Vedolizumab (entyvio)

23
Q

IL antagonists for CD and UC

A

Ustekinumab (stelara)
Risankizumab_rzaa (skyrizi)

24
Q

IL antagonist for UC

A

Mirikizumab- mrkz (Omvoh)

25
Q

JAK inhibitors for UC

A

Tofacitinib (Xeljanz)
Upadacitinib (Rinvoq)

26
Q

S1P receptor modulators used for UC

A

Ozanimod (Zeposia)
Estrasimod (Velsipity)

27
Q

TNF inhibitors class ADRs

A

Increased risk of infections, Injection site reactions, Risk of malignancy, Hepatosplenic T-cell lymphoma risk, Risk of demyelinating disease, may exacerbate CHF

28
Q

TNF inhibitors monitoring

A

CXR, PPD, S/S of infection, UA, CBC, SCr, electrolytes, LFTs, Hep B/C - all monitored at baseline and q 8-12 weeks

29
Q

Infliximab (Remicade)

A

Used for moderate to severe active CD and UC, Steroid- dependant or Fistulizing disease
TNF inhibitor
Used for induction and maintenance therapy

Monitoring in addition to class monitoring Maintenance, S/S of infection, vitals, infusion reactions, TDM

30
Q

Adalimumab (Humira)

A

Used for moderate to severe active CD and UC, steroid dependent
TNF inhibitor
can use for patients with poor response to infliximab

Used for induction and maintenance therapy

31
Q

Golimumab (simponi)

A

Used for Moderate to severe active UC, steroid dependent
TNF inhibitor
Induction and maintenance therapy

32
Q

Certolizumab Pegol (cimzia)

A

Used for mederate to severe active CD, Steroid dependent
TNF inhibitor
Induction and maintenance therapy

33
Q

Natalizumab (Tysabri)

A

Anti integrin
Used for CD induction and maintenance of remission

Can use in patients who fail TNF inhibitors

NOT used in combo with immunosuppressants

associated with progressive multifocal leukoencephalopathy (PML)

Monitor for neurological events

34
Q

Vedolizumab (Entyvio)

A

Anti integrin
Used for inducin and maintaining remission, decreasing steroid dependence for UC and CD

PML no commonly seen but still should be monitored

35
Q

Ustekinumab

A

IL-12 and IL-23 antagonist
used for CD and UC induction and maintenance

ADRs: Hypersensitivity, ADAs, Rapidly developing cutaneous cell carcinoma in patients with risk factors ( >60 YO, prolonged immunosuppressant therapy, and history of phototherapy), Possible neurotoxicity, TDM possible

36
Q

IL antagonist Monitoring

A

CXR, PPD - baseline
Hep B/C - baseline
Lipids - Baseline and q1-2months
LFTs - Baseline and q1-2months
Renal fnc - baseline and periodically
Infection - Baseline and monitoring s/s
Skin - baseline and annually

37
Q

Risankizumab-rzaa (Skyrizi)

A

selective IL-23 antagonist
Moderate to severe UC and CD

can be used for induction and maintenance

ADRs: Latent infection, headache, nasopharyngitis, arthralgia, abdominal pain, anemia, nausea

Monitor LFT and Biliruibin

38
Q

Mirikizumab-mrkz (omvoh)

A

IL-23p19 antagonist
For moderate to severe UC
used for induction and maintenance

ADRs: headahce, arthralgia, rash, injection site reaction, Infection/latenet infections (TB) potential hepatotoxicity

39
Q

TDM of biologics

A

Potential for determining concentration of drugs and ADAs

consider if loss of treatment response

if patient has ADAs present and low drug concentration - change to a different drug in the SAME class

If patient has ADAs present and regular drug concentration present - Switch to a new drug out of that class

If patient DOES NOT have ADAs and low drug concentration - increase dose

If patient DOES NOT have ADAs and regular drug concentration - Switch to new drug out of the class

40
Q

Tofacitinib (Xeljanz)

A

JAK inhibitor
For UC only
For patients who have had an inadequate response or who are intolerant to TNF blockers
Should not be used in combo with immunosuppressants

ADRs: diarrhea, elevated cholesterol, headache, herpes zoster, increased creatine phosphokinase, nasopharyngitis, rash, URI

Ensure vaccines are upto date, avoid if active infection

BLACK BOX warning:
Increased mortality in RA patients 50 YO or older with at least one CV risk factor, Thrombosis, Increased risk of death

41
Q

JAK inhibitor monitoring

A

CXR, PPD - baseline
Hep B/C - baseline
ANC/ALC - baseline and q3M
CBC - baseline and q1-2M
Lipids - baseline and q1-2M
LFTs - baseline and q1-2M
Infection - baseline and monitoring s/s
Skin exam - baseline and periodically

42
Q

Upadacitinib (Rinvoq)

A

JAK inhibitor
Oral selective inhibitor approved for UC and CD
who have had an inadequate response to or who are intolerant to TNF blockers
Should not be used in combo with immunosuppressants

ADRs: Black box warning same as tofacitinib, increased risk of infections, avoid if active infection, ensure vaccinations up to date, live vaccinations are contraindicated
Upper respiratory tract infection, acne, increased creatine phosphokinase, elevated cholesterole, headaches, herpes zoster

43
Q

Ozanimod (Zeposia)

A

S1P inhibitor
approved for moderate to severe active UC
Should not be used with non-corticosteroid

Drug interactions: CCB, Beta blockers, Adrenergic and serotonergic drugs, MAO inhibitors, CYP2C8 inhibitors and inducers

Contraindicated in patients who in last 6M experienced: MI, Unstable angina, stroke, TIA, decompensated heart failure, Class III or IV heart failure
- Mobitz type II 2nd or 3rd degree AV block
- Severe untreated sleep apnea

44
Q

S1P ADRs

A

Potential increase risk of infection
Bradycardia/AV conduction delay
Liver injury
Moderate increase in systolic BP
Respiratory effects
Macular edema
RPLS/PRES

45
Q

S1P Monitoring points

A

CXR, PPD - baseline
Hep B/C - baseline
CBC - baseline and periodically
LFTs - baseline and periodically
Infection - baseline and s/sx
BP - Each visit
Spirometry - if clinically indicated
ECG - baseline
optho - regular exams

46
Q

Estrasimod (Velsipity)

A

S1P receptor modulator
Approved for moderate to severe active UC

47
Q

S1P contraindications

A

Contraindicated in patients who in last 6M experienced: MI, Unstable angina, stroke, TIA, decompensated heart failure, Class III or IV heart failure

PHRM 864 - EXAM 4 (8 decks)

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