Irritiable bowel diseases Flashcards
What are the primary aims of IBD management?
- To induce and maintain remission (either clinical or endoscopic)
- Reduce the risk of complications
- Improve patient quality of life
What are the symptoms of Crohn’s relapse?
Weight loss, abdominal pain, diarrhoea and general ill-health.
Ulcerative Colitis vs Crohn’s?
Location
Symptoms
What are the criteria for UC to be labelled as Acute severe ulcerative colitis (ASUC)?
Defined by the modified Truelove and Witts criteria as:
* >6 bloody stools per day and systemic toxicity with at least one of:
* Temperature >37.8°C
* Pulse >90 bpm
* Haemoglobin <105 g/L
* C-reactive protein >30 mg/L
Adult patients with ASUC or adolescents with a Paediatric Ulcerative Colitis Activity Index (PUCAI) score of 65 or more should be admitted to hospital for assessment and intensive management
IBD affects how many people in the UK?
400 people per 100,000
What are the main drugs used in IBD?
- Aminosalicylates (mesalazine, sulfasalazine)
- Corticosteroids (such as prednisolone, beclomethasone and budesonide)
- Thiopurines (azathioprine, mercaptopurine)
What are aminosalicylates? How do they work?
5-aminosalicylic acid (5-ASA) class of drugs (mesalazine and sulphasalazine) are considered safe and effective long-term treatment options for IBD
The mechanism of action of 5-ASAs is not well understood; however, they are thought to reduce inflammation by inhibiting release of interleukin-1 and preventing recruitment of leucocytes into the bowel wall
What are the main side effects of aminosalicylates?
Renal complications, drug-induced liver injury, dyspepsia, rash, urticaria and eosinophilia
Treatment of acute mild-moderate EXTENSIVE ulcerative colitis?
- Topical aminosalicylate + high dose oral aminosalicylate (Topical + Oral)
Studies have shown that a combination of high-dose oral and rectal mesalazine therapy is more effective at inducing remission of mild-to-moderate symptoms compared with oral therapy alone.
No improvement after 4 weeks:
- High dose oral aminosalicylate + 4-8 weeks oral corticosteroid (Oral + Oral)
If aminosalicylates contraindicated: 4-8 weeks oral corticosteroid
Maintenance treatment of mild-moderate ulcerative colitis?
Once in remission, 5-ASA therapy for UC should be reduced to a maintenance dose as appropriate, to limit adverse effects but still reduce the risk and frequency of flares
Ideally, all UC patients should be offered a combination of oral and enema 5-ASA
In mild-to-moderate UC, 5-ASAs are the treatment of choice and all patients should be offered a 5-ASA at a dose of 2.0-3.0g/day orally. Patients experiencing flare-ups can be escalated to 4.0–4.8 g/day
Methotrexate has no role in the maintenance of remission in UC.
True or False?
True
What are the monitoring and reporting requirements for Aminosalicylates?
Monitoring: Renal function before starting, 3 months later and then annually
Blood dyscrasias - sore throat, fever, rash, ulcers, bleeding - refer to A+E
Good practice to prescribe by brand name but not legal requirement
Sulfasalazine discolours bodily fluids what colour?
Colours body fluids orange/yellow (not harmful, avoid wearing contact lenses)
Treatment with 5-ASAs is not recommended for induction or maintenance treatment of Crohn’s Disease.
True or False?
True
Can be used if Crohn’s is mild and the patient cannot have, or decide not to have, steroids.
What is first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis? (present in both UC and CD)
What would be second and third line?
- Rectal + oral aminosalicylates (if mild, rectal mesalazine may suffice)
- Foam if have difficulty retaining liquid from enemas)
If no improvement after 4 weeks or patient does not want to use rectal formulations:
- Oral aminosalicylate
- Rectal or oral steroid for 4-8 weeks
What can be used for maintenance of proctitis/proctosigmoiditis?
Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
Avoids the sulfonamide-related side effects of sulfasalazine
(sulphonamides are CYP inhibitors)
Sulfasalazine is a combination of what two compounds?
5-ASA and sulfapyridine
Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects
Which aminosalicylates have rectal preparations?
Mesalazine and sulfasalazine
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects
What should be given in severe acute UC?
MEDICAL EMERGENCY
- IV corticosteroids (methylpred or hydrocortisone)
- Usually 100mg hydrocortisone QDS - If symptoms not improved after 72 hours:
- IV steroid + IV ciclosporin
- Surgery - Infliximab if cannot use ciclosporin
Step down to oral prednisolone 40mg a day, with an aim to taper over six to eight weeks (usually tapered by 5mg per week)
In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?
No improvements within 4 weeks of initial therapy. If patient is on beclometasone, discontinue this
What is first line treatment for patients with acute exacerbation mild-moderate proctosigmoiditis or left-sided UC?
- Topical aminosalicylate (Topical)
No improvement after 4 weeks:
- High dose oral aminosalicylate + topical aminosalicylate OR High dose oral aminosalicylate + 4-8 weeks of topical steroid (Topical + Oral)
- High dose oral aminosalicylate + 4-8 weeks of ORAL steroid (Oral + Oral)
What are second generation corticosteroids?
Beclomethasone diproprionate and slow release budesonide
They have high affinity for the intracellular glucocorticoid receptor in the GI tract
- Lower systemic availability owing to extensive pre-systemic metabolism within the mucosa of the small intestine and the liver
- ‘Topically acting’ even though they are taken orally
Ensure the brand is specified as they have slightly different sites of release and licensed indications
Once remission is achieved, these should be tapered over one to two weeks
Rectal steroid preparations can be used to treat proctitis, proctosigmoiditis and colitis in CD. Rectal mesalazine should be used for UC owing to higher efficacy.
True or False?
True
True or false: Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
TRUE
Why does oral budesonide have fewer systemic side effects than corticosteroids?
It exerts its action locally in the colon
Summary of rectal corticosteroid preparations to manage IBD
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon
What can be used to MAINTANANCE of left-sided or extensive UC?
Low dose oral aminosalicylate
If 2 or more flare ups in 12 months:
- Oral azathioprine or mercaptopurine
Which antacids can cause contipation and which can cause diarrhoea
Magnesium containing = laxative effects (diarrhoea)
Aluminium & Calcium containing= constipation effects
Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?
Within the first 3-6 months of starting treatment
Discontinue if these occur
What should patients on sulfasalazine be aware of (benign)?
May stain the urine and contact lenses yellow/orange
What type of laxative may be useful for proximal faecal loading in proctitis ulcerative colitis?
Macrogol
What is the patient counselling with aminosalicylates?
Report any unexplained bleeding, bruising
Salicylate hypersensitivity e.g. itching, hives
Yellow/orange bodily fluids - may stain contact lenses
Patient counselling points for administration of:
1. Suppositories
2. Rectal foams/enemas
1. Suppositories
* Insert before bed to minimise any leakage
* Wet the tip of the suppository with water or a water-based lubricant to make it easier to insert
* Try not to go to the toilet for an hour after inserting the suppository to give it time to work
* May experience leakage during the night. This is normal because the suppository starts to melt once inserted. Placing a towel on the bed may help to absorb any leaks
* If a suppository comes out within ten minutes of inserting it, do not worry. Try another suppository
2. Rectal foams/enemas
* Use enemas before bed to minimise leakage
* When administering the enema, stand with one leg raised on a chair or lie down on your side. This gently creates an opening for the enema applicator which can then be inserted into the bottom as far as possible
* If lying on your side, a pillow may help to lift the bottom up. You may also use a towel to absorb any leakage
* For sleeping, find a comfortable position that helps keep the liquid inside for as long as possible. The longer it stays in, the better chance it will work.
What are the red flag side effects of aminosalicylates?
Agranulocytosis, Bone marrow suppression, Neutropenia, Cardiac inflammation, nephrotoxicity
What are the monitoring requirements for aminosalicylates?
Renal function: before, at 3 months, and then annually
Liver function: Monthly for first 3 months
FBC: Monthly for first 3 months (drug should be stopped immediately if any indication of blood dyscrasia)
Patients should report any unexplained bleeding/bruising/fever/malaise during treatment
What is the interaction between lactulose and mesalazine?
The manufacturers of some mesalazine gastro-resistant and modified-release medicines suggest that preparations that lower stool pH (e.g. lactulose) might prevent the release of mesalazine.
Which GI conditions are the following drugs used for
Hyoscine butylbromide
Alverine Citrate
Mebeverine
(All) Gastro-intestinal smooth muscle spasms
Hyoscine: IBS, Acute spasms
Mebeverine: IBS
True or false: When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
TRUE
Which electrolytes are affected by PPIs
Hyponatreamia
Long term use: Hypomagnesaemia (more common after 1 year but sometimes after 3 months)
What are some side effects of Loperamide and what is the MHRA alert
Flatulence, GI disorders, Nausea, Headache, Dizziness, Dry mouth
MHRA alert: Serious cardiovascular events (e.g. QT prolongation, TDP, cardiac arrest) with large overdose, naloxone can be given as an antidote
What is the MHRA saftey alert with PPIs
Subacute cutaneous lupus erythematosus (SCLE)
development of lesions with associated athralgia
When is metoclopromide contraindicated for treating sickness?
3 - 4 days after Gastrointestinal surgery
GI heamorrhage
GI obstruction
Under 18 years due to neurological effects
Epilepsy
Parkinsons
Which of the following is not a typical symptom of IBS?
A. Abdominal pain
B. Bloating
C. Constipation
D. Diarrhoa
E. Emesis (vomiting)
Emesis (vomiting)
Why can Crohns disease cause secondary osteoporosis?
Reduced absorption of dietary vitamins and minerals.
What is fistulating Crohn’s disease?
When there is the formation of a fistula between the intestine and adjacent structures, such as the perianal skin, bladder, and vagina. It occurs in about 1/4 patients, mostly when the disease involves the ileocolonic area.
What common harmful lifestyle factor can make Crohn’s worse?
Smoking
In the treatment of acute Crohn’s, what is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn’s in a 12-month period?
A corticosteroid (either prednisolone, methylprednisolone or intravenous hydrocortisone).
Acute Crohns: In patients with distal ileal, ileocaecal or right-sided colonic disease in whom a conventional corticosteroid is unsuitable or contra-indicated, what can be considered and why?
Budesonide can be considered, it is less effective but may cause fewer side-effects than other corticosteroids as the systemic exposure is limited.
Aminosalicylates (sulfasalazine and mesalazine) are an alternative option. But less effective.
What are immunomodulating therapies?
Thiopurines, methotrexate, ciclosporin and biologic or targeted cell therapies
When would add-on treatment be used in Acute Crohn’s?
If there are two or more inflammatory exacerbations in a 12-month period, or if the corticosteroid dose cannot be reduced.
All patients with IBD receiving immunosuppressants should also receive influenza, pneumococcal and COVID-19 vaccinations.
True or False?
True
But avoid live vaccines (BCG, MMR, flu nasal spray etc.)
Acute Crohn’s: What can be added to a corticosteroid or budesonide to induce remission?
Thiopurines such as azathioprine or mercaptopurine can be added.
In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.
How do thiopurines work?
Deactivate T-lymphocyte processes that lead to inflammation and are effective at maintaining steroid-free remission in CD and UC
Azathioprine is a pro-drug of 6-mercaptopurine
Should not be used to induce remission
When are thiopurines started in patients with:
1. Crohn’s
2. Ulcerative Colitis
Crohn’s
* Thiopurines can be added to glucocorticoids or budesonide to induce remission if the patient has had ≥2 exacerbations within a 12-month period or
* If tapering of glucocorticoids has failed
Monotherapy can be continued to maintain remission
Ulcerative colitis
* Thiopurines can be initiated if ≥2 exacerbations have occurred within a 12-month window or
* If remission is not maintained by 5-ASAs or after a single episode of acute-severe UC
Patients can be started on thiopurines in combination with biological treatment (e.g. infliximab) to minimise drug antibody development.
True or False?
True
A higher immunosuppressant effect (and therefore higher doses of thiopurines) is required in patients with IBD to achieve disease remission.
True or False?
True
The therapeutic target for IBD patients on azathioprine is 2–2.5mg/kg, and 1–1.25mg/kg for mercaptopurine monotherapy if thiopurine
methyltransferase [TPMT] is normal
Main side effects of thiopurines (azathioprine, mercaptopurine)?
- Nausea (advise patients to take their tablets after meals)
- Severe diarrhoea (with azathioprine, recurs on rechallenge)
- Myelosuppression and opportunistic infections
- Deranged liver function and hypersensitivity reactions, including pancreatitis
Long-term thiopurine use may also be associated with an increased risk of lymphoproliferative disorders and non-melanoma skin cancer. The risk of lymphoma rises markedly with increasing age
Monitoring requirements for thiopurines (azathioprine, mercaptopurine)
Thiopurines are associated with a high risk of toxicity and careful monitoring is advised
What are TPMT levels and why are they tested when taking thiopurines?
Individual TMPT (thiopurine S-methyltransferase) activity determines the extent of mercaptopurine metabolism
There is increased risk of severe and potentially fatal myelosuppression at standard doses in patients who have no or low levels of activity. Thiopurines should be avoided in people with zero TPMT levels
Myelosuppression secondary to thiopurines is dose related and generally reversible.
True or False?
True
Commonly features leucopoenia, thrombocytopenia and transaminitis (raised LFTs)
Myelosuppression can be aggravated in those patients with low or deficient levels of TPMT.
What are TGN levels, what is the therapeutic level and when should they checked?
Tests for TGN levels determine the thioguanine count in DNA structure and should ideally be requested at weeks 4 and 12 after starting therapy, thereafter bi-annually/annually, or 4 weeks after a dose change
A therapeutic TGN range of 235–450 pmol/8 x 108 red blood cells (RBCs) correlates with a sufficient clinical response
Increasing the dose by 25–50mg per day may be sufficient for TGN to reach therapeutic range, if subtherapeutic. Equally if levels are above range, reducing the dose by 25–50mg may be enough to bring it down to range
How long should elapse between completion of cancer treatment and starting therapy for IBD with thiopurines or biologics?
2 years
Although this depends on the agent being considered and availability of other options to control disease
Acute Crohn’s: Add-on treatment: In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, what can be added to a corticosteroid?
Methotrexate
Under specialist supervision, what are options for the treatment of severe, active Crohn’s disease, following inadequate response to conventional therapy?
Adalimumab, Infliximab
How does adalimumab work?
anti TNF
How does infliximab work?
Anti TNF
In the maintenance of remission in Crohn’s, which drugs can be used as unlicensed monotherapy to maintain remission?
Azathioprine and mercaptopurine
Methotrexate should only be used in Crohn’s patients to maintain remission if what?
if they are intolerant of or not suitable for azathioprine or mercaptopurine treatment.
What drugs should not be used for the maintenance of remission in Crohn’s?
Corticosteroids or budenoside.
use to induce remission only
What drug is licensed for the relief of diarrhoea associated with Crohn’s disease?
Colestyramine
loperamide and codeine can also be used.
What is diverticular disease?
Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain in the absence of inflammation or infection. Can cause large rectal bleeds
40 years and over usually
Symptoms of diverticular disease: lower abdominal pain, change in bowel movements – constipation or diarrhoea, rectal bleeds, fever
What is the treatment for diverticular disease
High fibre diet or bulking forming laxatives for constipation symptoms
Paracetamol for pain
Not recommended in diverticular disease – antibiotics, NSAIDs, opioids
What is not recommended in uncomplicated diverticular disease?
Antibiotics unless the patient presents with signs of infection/immunocompromised
the use of NSAIDS or opioids is not recommended in uncomplicated diverticular disease
What is the treatment for complicated diverticular disease?
Hospital admission required - IV antibacterials covering gram negative and anaerobes & Bowel rest
True or false:
There is insufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis.
TRUE
Balsalazide is a pro drug of what?
5-ASA (Mesalamine)
What are extraintestinal manifestations?
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
In a patient with a first presentation or single inflammatory Crohn’s exacerbation in a 12 month period, what drug is used?
If this is not suitable, or if the patient has right-sided colonic disease, what could be used? When would these not be appropriate and why?
- Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
- Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
When would you add in additional treatment (on top of steroid monotherapy) in a Crohn’s disease exacerbation?
What would you add?
2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced
Azathioprine or mercaptopurine
Is mercaptopurine licensed in severe UC or CD?
No
What can be added to a steroid to induce remission in a Crohn’s patient?
If these are not suitable, what could be used?
- Azathioprine, Mercaptopurine (unlicensed)
- Methotrexate
What test do you need to do before starting someone on azathioprine or mercaptopurine?
TPMT levels. If activity is deficient, it may not be suitable
FBC weekly for 4 week, then every 3 months
Patients should be advised to monitor for signs of bone marrow suppresion
What monoclonal antibodies are licensed for Crohn’s?
Adalimumab
Infliximab - can also be used for active fistulating CD
Literature supports the use of which biologic as a first-line biologic option for UC failing conventional therapy?
Vedolizumab
Can be used in the induction and maintenance of remission of ulcerative colitis in patients where anti-TNF treatment has failed
Tofacitinib as an oral agent, with no concerns about immunogenicity. True or False?
True
Tofacitinib can be used in the induction and maintenance of remission of ulcerative colitis in patients where anti-TNF treatment has failed
It is an attractive choice, but with little real-world experience as yet
Tofacitinib increases the risk of what infection?
What if vaccination is required?
Herpes zoster
Occurred more often on active treatment
Vaccination should be considered before starting therapy in those aged over 70 years and those over 50 years considered at particularly high risk (such as recurrent shingles)
- As a live vaccination it must not be given for 3 months after stopping biologics, and tofacitinib should not be started for 4 weeks after vaccination
Tofacitinib increases the risk of PE at what dose?
5-fold increase in pulmonary embolus for the group on 10 mg BD tofacitinib compared with TNF inhibitor therapy (as compared to 5mg BD)
EMA committee advises that the high dose should not be used in patients at increased risk of pulmonary embolus (heart failure, malignancy, impending/recent surgery, inherited coagulation disorders, previous thromboembolism, combined contraceptive therapy or HRT).
Should steroids be used for the maintenance of remission for Crohn’s?
No- only to induce remission
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?
No need for treatment if asymptomatic
To improve symptoms (but not fully heal):
Metronidazole and/or ciprofloxacin (unlicensed)
- Metronidazole for 1 month but no more than 3 months (peripheral neuropathy)
If metronidazole is given for fistulating Crohn’s, how long for and what are the associated risks?
1 month (no longer than 3) due to risk of peripheral neuropathy
What is used to control the inflammation in fistulating Crohn’s disease (and continued for maintenance)? How long should they be on this for?
Azathioprine or mercaptopurine (unlicensed) or infliximab
For at least 1 year
What should a patient be screened for if starting vedolizumab?
TB
Contraindicated in those with TB
How are IBS patients with:
Diarrhoea
Constipation
Spasms
Pain
Diarrhoea - loperamide
Constipation - laxatives (avoid lactulose - bloating)
Spasms - antispasmodics (alverine, mebeverine, peppermint oil), hyoscine butylbromide (avoid in cardiac disease - antimuscarinic)
If OTC pain management is not working: amitriptyline or SSRI (unlicensed)
Patients on colestyramine long term may need supplements of vitamins A, D, E, K, and folic acid. Why?
Can intefere with absorption of fat soluble vitamins
What is the advice around taking colestyramine with other drugs?
Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.
Constipation red flags?
B - blood in stools
A - anaemia
A - abdominal pain
W - weight loss
N - New onsent constipation in over 50s
How can people experiencing diarrhoea and high output stomas be treated?
Loperamide and codeine
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
What are the warnings associated with liquid paraffin as a lubricant?
Anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.Should not be taken immediately before going to bed
What is 1st line for short duration constipation where dietary measures have not helped?
If stools are soft but difficult to pass, what would be more appropriate?
- BOS
Soft but difficult to pass: Stimulant laxative
How is chronic constipation managed? (>6 months)
BOS
- Bulk forming
- Change to or add osmotic laxative (macrogol, lactulose second line)
If no change after 6 months:
- Prucalopride (now also used in men)
Lactulose should be withdrawn slowly
What is the duration of acute diarrhoea
Less than 14 days
What is the maximum daily licensed dose for loperamide?
16mg (8 x 2mg capsules)
What is the MHRA advice regarding loperamide?
Reports of serious cardiac adverse reactions with high doses associated with abuse QT prolongation, torsades de points, cardiac arrest
What is a side effect of magnesium?
Laxative effect
What is a side effect of aluminium?
Constipation
Referral criteria for dyspepsia/GORD?
G - Gastrointestinal bleeding
A - Age over 55
U - Unexplained weight loss
D - Dysphagia
What 2 electrolytes can drop if on PPIs?
Sodium and magnesium
What is the MHRA alert associated with hyoscine butylbromide injection (IM, IV, SC)?
Can cause serious side effects such as tachycardia, hypotension, anaphylaxis (which is likely to be fatal in patients with CHD)
It is therefore contraindicated in patients with tachycardia and should be used in caution in those with cardiac disease
If a patient has an aspirin sensitivity, would aminosalicylates be appropriate for them?
No - sulfasalazine and mesalazine are derivatives of salicylates, like aspirin.
What colour does your urine turn if on sulfasalazine?
Yellow/orange
What age is Mintec peppermint capsules licensed for?
> 18 years
What age is Colpermin peppermint capsules licensed for?
>15 years
What is the MHRA advice surrounding PPIs?
Very low risk of subacute cutaneous lupus erythematosus
Drug-induced SCLE can occur weeks, months or even yearsafter exposure to the drug.If a patient on PPIs develops lesions in sun-exposed areas
- Accompanied with arthralgia
Advise them to avoid sun exposure
Consider SCLE as a possible diagnosis
What are long term complications of ulcerative colitis?
Colorectal cancer, Osteoporosis - from dietary change, corticosteroid medication,VTE,Toxic megacolon
The use of loperamide or codeine in an acute flare up of UC increases the risk of what?
Toxic megacolon
What are the complications of Crohn’s Disease?
Intestinal strictures, abscesses, fistulae, Malnutrition Anaemia, Colorectal and small bowel cancers, Growth failure and delayed puberty in children, Arthritis, Secondary osteoporosis - from steroid meds
Loperamide dosing
1-2 tabs at first then 1 tab with each loose stool (max 8 x 2mg)
OTC: 12+
Prescription: 4+
What are the red flag symptoms of constipation?
New onset in > 50 years
Anaemia
Abdominal pain
Unexplained weight loss
Change in bowel habit
What is the advice with enteral feeds and food when taking sucralfate?
Administration of sucralfate and enteral feeds should be separated by 1 hour and for administration by mouth, sucralfate should be given 1 hour before meals.
What are the side effects of antimuscarinics?
Blurred vision
Arrhythmias
Pupil dilation (mydriasis)
Urinary retention
Constipation
Dry mouth
Angle-closure glaucoma
Drowsiness, confusion
What is diverculosis and treatment?
Asymptomatic
Forms diverticula= small pouches protruding from large intestine
Treatment: Bulking forming laxatives if they have constipation, paracetamol
What is acute diverticulitis
Sudden inflammation of diverticula
Can be infected = pain, fever, rectal bleeding
Treat with antibiotics
What is complicated acute diverticulitis
Access, bowel perforation, fistula, intestinal obstruction, haemorrhage, sepsis
What is treatment for acute diverticulitis
Paracetamol if no systemic symptoms, antibacterials if needed and low fibre diet generally in diverticulitis
What is treatment for complicated acute diverticulitis
Hospital
What is not recommended in complicated acute diverticulitis
Aminosalicylates and propylactic antibacterials
What drugs are used in IBD
Aminosalicylates: Sulfaslazine, sulfapyridine, mesalazine, balsalazide, olsalazine
Cytokine modulators: Infliximab, adalimumab, golimumab
Infliximab, adalimumab and golimumab are licensed for which condition?
Infliximab and adalimumab are licensed for both UC and CD with comparable efficacy, while golimumab is currently licensed for UC only
PPIs increase concentrations of what drugs?
Methotrexate
Laxative abuse can lead to what?
Can cause hypokalaemia and lazy bowel syndrome/incontinence
