Large Bowel Pharm Flashcards
Treatment of Ulcerative Colitis and Crohn’s Disease
5 drugs
- Aminosalicylates
- Corticosteroids
- Antibiotics
- Immunosuppresive agents
- Biological Agents
Drugs that are used for treatment are based on?
4
- Severity of disease
- Ulcerative colitis
- Crohn’s disease location of lesions
- Exacerbation vs. maintenance therapy
Drugs used for treatment of inflammatory bowel disease
- Aminosalicylates
- used how? 2 - Corticosteroids
- Used how?
- Should not be used for what?
- Mild to moderate UC and CD exacerbations
- Maintenance of remission
- Treatment of UC and CD acute exacerbations
- Should not be used chronically to maintain remission
Drugs used for treatment of inflammatory bowel disease
- Antibiotics
- Used for? - Immunosuppresive agents
- Used for?
- Acute exacerbations and maintenance of remission
2. To maintain remission
Drugs used for treatment of inflammatory bowel disease
1. IV cyclosporine
used for?
2. Immune modifiers used for?
- Severe active steroid refractory UC
2. Maintain remission in steroid refractory UC and CD
Treatment Options for Crohn’s and Ulcerative Colitis: Describe treatment of Distal UC 1. Mild 2. Moderate 3. Severe 4. Remission
Severity of Disease
Distal UC
- Mild
Oral/rectal aminosalicylate or rectal corticosteroid - Moderate
Oral Aminosalicylate and oral/rectal steroids and/or immunosuppressive - Severe
IV corticosteroids with/without IV cyclosporine - Remission
Oral/rectal aminosalicylate with/without oral immunosuppressive
Treatment Options for Crohn’s and Ulcerative Colitis: Describe treatment of Extensive UC? 1. Mild 2. Moderate 3. Severe 4. Remission
Extensive UC
1. Mild- Oral Aminosalicylate
- Moderate- Oral Aminosalicylate and oral steroids and/or immunosuppressive
- Severe- IV corticosteroids with/without IV cyclosporine
- Remission- Oral/rectal aminosalicylate with/without oral immunosuppressive
Treatment Options for Crohn’s and Ulcerative Colitis: Describe treatment of CD? 1. Mild 2. Moderate 3. Severe 4. Remission
CD
1. MIld- Oral Aminosalicylate with/without antibiotics
- Moderate- Oral Aminosalicylate and oral steroid and/or immunosuppressive
- Severe- IV corticosteroids with/without IV cyclosporine
- Remission- Oral Aminosalicylate with/without oral immunosuppressive
What are the Aminosalicylates?
4
- Sulfasalazine (Azulfidine)
- Mesalamine (Asacol, Pentasa)
- Olsalazine (Dipentum)
- Basalazide (Colazal)
Aminosalicylates clinical uses
2
- Induce and maintain remission in UC
- Efficacy in Crohn’s is not well established, but often used as 1st line tx of Crohn’s involving the colon or distal ileum.
Aminosalicylates forms of administration?
3
- PO
- Enema
- Suppository
Aminosalicylates: Sulfasalazine (Asulfidine)
- Preg cat?
- Converted to what in the proximal colon?
- Take how many times daily?
- Contraindication?
- Pregnancy cat. B (Sulfapyridine-mesalamine compound)
- Converted to mesalamine in the proximal colon
- Tablets administered 4 times daily
- Contraindicated in sulfa allergy
Aminosalicylates: Mesalamine (Asacol, Pentasa)
- Preg cat?
- Poorly absorbed in the GI tract so works primarily like a topical agent with what kind of effects?
- Describe the four ways of administration?
- B
- limited systemic SE and drug interactions
- -Oral tablets (Asacol)
released in the distal ileum and colon
-Oral capsules (Pentasa)
released in the proximal small intestine and throughout the colon
-Enema
Can reach distal and sigmoid colon, administered at bedtime
Rectal suppositories
-Primarily used for UC proctitis
Aminosalicylates: Basalazide (Colazal)
- Preg cat?
- Converted to mesalanine where?
Olsalazine (Dipentum)
- Preg cat?
- Converted to mesalanine where?
These 2 drugs are not used as much as the others due to the increased cost but no added efficacy
Both are poorly absorbed in the GI tract so work primarily like a topical agent with limited systemic SE and drug interactions
Basalazide (Colazal)
- Pregnancy cat. B
- Converted to mesalamine in the proximal colon
Olsalazine (Dipentum)
- Pregnancy cat. C
- Converted to mesalamine in the proximal colon
MOA Aminosalicylates
3
- Blocks prostaglandin production
- Perhaps interferes with production of inflammatory cytokines
- May inhibit natural killer cells, lymphocytes and macrophages
Exact mechanism unknown
Contraindications to Aminosalicylates
3
- Aspirin or other salicylate allergy
- Glucose-6-phosphate dehydrogenase deficiency
- Sulfasalazine is contraindicated with a history of sulfa allergy
Dosing of Aminosalicylates?
- What must we dose at?
- SE increase with what?
- Must be used at max doses for maximum therapeutic benefit
- Side effects increase as the dose increases
- Dosing varies from once daily to four times daily depending on the formulation
Side effects of sulfasalazine 5
Severe rxns? 5
What do we need to supplement with?
- Worst side effect profile of all the aminosalicylates
- Nausea, Vomiting
- Photosensitivity, oligospermia
- Skin discoloration
- Decreased folate levels
Severe:
- Steven-Johnson syndrome,
- crystalluria,
- pancreatitis,
- hepatitis,
- bone marrow suppression
Need to take a folic acid supplement
What do we need to monitor with Sulfasalazine and how often? 2
Periodically what else? 2
- CBC with differential,
- LFTs prior to therapy then every other week for 3 months, then every month for 3 months, then quarterly
Periodic renal and LFTs
Side effects of mesalamine & it’s compounds
Mesalamine 4
Olsalazine 1
Balsalazide 1
Rarely these can be associated with what?
Mesalamine
- Headache,
- malaise,
- abdominal pain and
- diarrhea
Olsalazine
1. Similar to mesalamine but has more severe secretory diarrhea
Balsalazide
Similar to mesalamine
1. If capsules opened and sprinkled in food may cause staining of the teeth
Rarely can be associated with renal impairment
Mesalamine
No specific recommendations on how frequent to monitor these labs
-Which ones? 3
- Renal function prior to and during therapy
- CBC
- Hepatic function
Corticosteroids
- Used for what?
- Short term side effects? 6
- Long term side effects? 5
1. Used for acute exacerbations Not used for maintaining remission 2. Short term side effects -Increased glucose levels, -increased appetite, - insominia, anxiety, - tremors, -increased fluid retention, -increased blood pressure
Long term side effects
- Decreased bone mineral density,
- fat redistribution,
- ulcers from decreased prostaglandin production,
- hypertriglyceridemia,
- hirsutism
Prednisone (Deltasone) and Prednisolone (Prelone) are most commonly used oral medications
- Initial dose? then what?
- IV formulas? 2
- 40-60mg/d initially
Taper with patients response - IV – Hydrocortisone (Solu-Cortef) and Methylprednisolone (Solumedrol)
- Budesonide (Entocort) is what?
- It is used how for treatment?
Budesonide (Entocort)
- Controlled release with limited systemic absorption
- Has been used as the treatment of choice in patients with mild to moderate CD in combo with 5-ASA or as mono therapy
What are the topical steriods?
3
What is this used to treat?
- Cortenema,
- Cortifoam,
- Anusol-HC suppositories
- Hydrocortisone enemas, foam or suppositories - For IBD involving the rectum/sigmoid colon
Sometimes referred to as topical
Antibiotics are generally used for the treatment of what?
- Used generally for treatment of Crohn’s disease that does not respond to 5-ASAs after 3-4 weeks or if the patient is intolerant to 5-ASAs
Efficacy in Ulcerative colitis has not been established
What antibiotics are used in the treatment of Crohn’s?
2
- Cipro
2. Metronidazole (Flagyl)
- Why do we use cipro for crohns?
2. May take up to how long for remission?
- May have some immunosuppressive properties
2. May take up to 6 weeks for remission
- HOw should we administer Flagyl?
- May have what kind of properties?
- May take how long to respond to therapy?
- Duration of therapy may be up to how long?
- Start at a higher dose and decrease after response is noted
- Likely also has some immunosuppressive properties
- May take 1-2 months for response to therapy
- Duration of therapy may be up to 12 months