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Lower gastro-intestinal diseases > Pharmaceutical care issues in IBD > Flashcards

Pharmaceutical care issues in IBD Flashcards

1
Q

What are some of the infections that patients with IBD are at an increased risk of?

A

Enteric infections specifically caused by:

Norovirus
E coli
Clostridium difficle
Campylobacter

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2
Q

What can these infections cause?

A

Flare ups and altered immune responses

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3
Q

Why are patients with IBD at an increased risk of infection?

A

On immunosuppressant drugs which increases susceptibility

Disease state itself increases the risk

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4
Q

How is infection ruled out as a cause of flare ups in IBD?

A

In patients with IBD presenting in hospital with diarrhoea as a primary symptom will have stool samples collected to test for the presence of infection.

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5
Q

What consideration must be made when deciding appropriate treatment for infections in patients with IBD?

A

Must consider whether an antibiotic is going to interact with any IBD medicines that the patient is currently taking and which may reduce the effectiveness of treatment and clearance.

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6
Q

What are the risks of C. diff infections in patients with IBD?

A

Increased risk of colectomy and mortality in these patients

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7
Q

When is the risk of a patient with IBD contracting Cytomegalovirus higher?

A

When the patient has:
Refractory disease
Receiving immunomodulating therapy
Receiving corticosteroids

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8
Q

What is the appropriate pharmaceutical management for patients who have contracted Cytomegalovirus?

A

IV Ganciclovir followed by PO Valganiclovir

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9
Q

What are some of the strategies used to reduce potential for infection which should be investigated at diagnosis?

A

Infection history of the patient - including herpes simplex and chicken pox

Immunisation history of the patient - including MMR, Rotavirus, Dipetheria, Tetanus etc

Screening for any latent infections such as latent TB, HIV or HepB or C so they can be treated appropriately before starting immunomodulating therapy

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10
Q

If the patient is unsure about immunity what should be done?

A

Serological tests which can be used to detect whether the patient has any immunity

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11
Q

What is a crucial intervention regarding steroid use in IBD?

A

Steroids are used in the acute treatment of IBD however should not be used in maintenance therapy so must be titrated accordingly after treatment (withdrawal dose) of a flare with the intention of stopping the therapy.
If a steroid is not titrated appropriately after use in acute treatment there is a risk of adrenal insuffiency and early relapse.

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12
Q

What percentage of patients with IBD have steroid excess (two or more courses in a year) or dependence?

A

14.9%

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13
Q

What are some of the side effects of steroid use?

A

Increased risk of infections
Osteoporosis
Adrenal suppression
Diabetes
Weight gain
CVD

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14
Q

What are some of the monitoring parameters required for a patient taking steroids?

A

Full blood count
HbA1c
Blood pressure
Lipids
Mood
Sleep
Eyes (cataracts, glaucoma)

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15
Q

What percentage of patients with IBD also have osteopenia?

A

35-40%

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16
Q

What percentage of patients with IBD have osteoporosis?

A

15%

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17
Q

What are some of the risk factors for poor bone health?

A

Uncontrolled inflammation
Malabsorption
Weight loss
High dose steroids
Lack of physical exercise
Alcohol intake

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18
Q

What is a pharmaceutical intervention to maintain good bone health in patients with IBD?

A

Patients with IBD that are taking corticosteroids should receive:

800-1000mg of calcium and 800IU of Vitamin D

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19
Q

Which vitamin deficiency is common for patients with IBD?

A

Vitamin D

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20
Q

What are the ongoing monitoring parameters for IBD patients to prevent osteoporosis?

A

Risk of osteoporosis and osteopenia checked regularly in addition to calcium and Vitamin D levels.

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21
Q

How should high and low risk IBD patients for osteopenia/osteoporosis be managed?

A

Low risk: retest in 3-5 years

High risk: initiate a bisphosphonate

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22
Q

Why is malnutritional common in IBD?

A

Increased nutritional demand due to inflammation
Poor absorption due to inflammation
Or surgery

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23
Q

What specific deficiencies are common in IBD?

A

Magnesium
Calcium
Vitamin D
Potassium

Not easy to identify due to disease state

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24
Q

How many patients with IBD have magnesium deficiency?

A

13-88%

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25
Q

What is used to correct a magnesium deficiency?

A

PO or IV Magnesium

PO use with caution due to potential to worsen diarrhoea

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26
Q

What is used to correct a potassium deficiency?

A

IV or PO such as Sando-K

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27
Q

What is the proportion of patients with IBD that have iron deficient anaemia?

A

1/3 of patients

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28
Q

What are the effects of iron deficient anaemia?

A

Fatigue
Reduced quality of life
Delayed recovery

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29
Q

What causes iron deficiency in periods of inflammation?

A

Increased blood loss and active bleeding
Increased iron excretion
Reduced intake of iron
Reduced transport of iron in the blood
Erythropoiesis as a result of inflammation

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30
Q

What causes iron deficiency during periods of quiescence?

A

Inadequate iron repletion after active disease
Ongoing low grade inflammation
Poor intake
Low intake of food that helps iron absorption
High intake of foods that inhibits iron absorption

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31
Q

What are some dietary recommendations that help the increase levels of iron?

A

Iron fortified foods
Non-haem iron and haem iron foods
Foods that promote iron absorption
Avoid foods that inhibit iron absorption

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32
Q

What is some of the monitoring requirements for iron levels in patients with IBD?

A

Annual FBC, Ferritin and CRP levels

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33
Q

What are the limitations of using oral iron in IBD?

A

Can cause constipation and diarrhoea
Absorption for GI tract is reduced and any unabsorbed iron is then exposed to ulcerated intestinal surface, furthering harming the mucosal.

34
Q

Taking into consideration the side effects of PO iron, are there any circumstances they can be used in IBD patients?

A

IBD patients when the disease is inactive with mild anaemia

Maximum dose is 100mg of elemental iron

35
Q

When is IV iron first line treatment?

A

Patients with:
Clinically active IBD
Severe anaemia
Intolerant to oral iron

36
Q

What are the benefits of IV iron?

A

Faster acting
More effective
Better tolerated

37
Q

Once anaemia in patients with IBD is corrected what is the ongoing monitoring that is required?

A

Every 3 months for a year then every 6-12 months onwards to ensure they are no longer anaemic.

38
Q

What are some of the other causes of anaemia?

A

Vitamin B12
Folate
Chronic disease
Bone marrow depression

39
Q

What are some of the risks of smoking?

A

Increased risk of bowel and lung cancer
Increased risk of cardiovascular disease
Increased risk of lung disease
Increased risk of stroke

40
Q

Is smoking more common in Crohn’s or Colitis?

A

Crohn’s disease (smokers are twice as likely to be diagnosed with Crohn’s disease)

41
Q

If smoking is continued in Crohn’s disease what are the potential outcomes?

A

Worse surgery outcomes
Increased risk of surgery
Worse disease course

42
Q

What is the relation between UC and smoking?

A

More common in non-smokers and is more likely to rise after quitting (first 2-5 years).

43
Q

If smoking is continued in UC what are the potential outcomes?

A

Reduced surgery rates
Less extensive disease
Reduced need for therapy

44
Q

If a patient with UC is still smoking what advice should be given?

A

Even though smoking is associated with a protective effect in UC, smoking cessation should still be encouraged and the patient advised of the widespread harm associated with smoking.

45
Q

What pharmaceutical changes must be made when a patient with UC stops smoking?

A

Potential increase in dose of medication
Patient warned of the increase in potential for flares

46
Q

Is use of NSAIDS suitable for patients with IBD?

A

May increase disease activity and precipitate relapse.

However there is conflicting evidence and the British Gastro-enterology society suggests that low dose short term use in patients with controlled IBD is potentially safe.

Overall avoid use of NSAIDs (even COX-2 selective NSAIDS)

47
Q

What cancer are patients with IBD (UC specific) at increased risk at developing?

A

Colorectal cancer (colon and rectum cancer)

48
Q

In UC what specific factors increase the risk of colorectal cancer?

A

Duration of disease
Amount of bowel affected
Severity of inflammation

49
Q

What types of IBD are at the greatest risk of colorectal cancer (location of inflammation)?

A

Greatest:
Extensive then
Distal (left sided) then
Proctitis (no increased risk)

50
Q

When does the increased risk of colorectal cancer begin?

A

8-10 years after the onset of SYMPTOMS not diagnosis

51
Q

What is the cumulative risk of developing colorectal cancer with IBD?

A

1% at 10 years
2-3% at 20 years
5-7% at 30 years

52
Q

What types of cancer are patients with Crohn’s disease at specific risk of?

A

Same risk as UC with colorectal cancer if the colon is the main organ affected but also:

Cancer of the small bowel, intestinal lymphoma, anal cancer

53
Q

What are some of the management strategies to reduce the risk of bowel cancer development?

A

Treatment for controlling inflammation
Annual specialist reviews
Colonoscopies for monitoring
Lifestyle modifications to reduce overall risk of bowel cancer development

54
Q

How frequently would somebody with IBD have colonoscopies for cancer monitoring?

A

Frequency is highly dependent on the presence of other risk factors and disease characteristics (disease activity, strictures etc).

Usually between 1-5 years

55
Q

What are some of the lifestyle modifications to reduce overall bowel cancer risk?

A

Eating less processed foods and red meat
Eating more fibre
Drink less alcohol
Stop smoking
Be active
Keeping a healthy weight

56
Q

What vaccination advice should be given for IBD patients?

A

Keep up to date with COVID vaccines
Ensure the patient receives no live vaccines whilst on immunomodulating therapy
Patients should have the flu vaccines annually
Patients should receive the pneumococcal vaccine, at least 2 weeks before receiving immunosuppressants

57
Q

Do IBD patients have a complete antibody response to COVID vaccines / vaccines in general?

A

Patients on aminosalicylates or on no treatment are believed to develop a full antibody response

Patients on immunosuppressants are believed to have a reduced antibody response but should still receive the vaccine and it is thought to improve with the second dose.

58
Q

What are some of the reasons for poor adherence in IBD patients?

A

Issues with medication (side effects)
The medication is long-term
Having to taken medication even in absence of flares
Topical treatments
Need for monitoring
Patient beliefs

59
Q

What are the consequences of poor adherence of IBD medication?

A

Increase in disease activity
Relapse
Loss of response
Higher morbidity/mortality
Poor quality of life
Higher disability

60
Q

What are some of the strategies to improve IBD medicine adherence?

A

Education
Visual reminders
Simplification of dosing

61
Q

What is an ileostomy?

A

Ileum is brought to the surface of the abdomen.
Contents are soft due to contents not passing through the colon where the remainder of water is absorbed.

62
Q

What is a colostomy?

A

Colon is brought to the surface, contents are semi or fully formed.

63
Q

What are the important pharmaceutical considerations that need to be made when a patient has a stoma?

A

Monitoring output
Knowledge of the site of the stoma and the function of the remaining bowel
Loss of absorption of nutrients and drugs

64
Q

What is short gut syndrome?

A

Lack of function of the small bowel, and affects nutritional status and loss of electrolytes, oral medication absorption.

65
Q

In regards to stoma use, which pain control medicines should be used?

A

Ideally paracetamol
Opioid use can cause constipation, use with caution
NSAIDs should be monitored for blood traces

66
Q

In regards to stoma use, which formulations should be avoided?

A

Ideally give liquid or non-coated tablet form as enteric and modified release preparations there is a risk that the drug will not be able to undergo its release profile due to not having a fully functioning bowel.

67
Q

In regards to stoma use, why are antimotility drugs used?

A

Slows down the gut, allows more water to be absorbed and reduce the high output volume in stomas.

Loperamide is used more often over codeine (due to the effects of opioids).
In these patients, doses of loperamide are much higher (max. 64mg)

68
Q

What are the risks of using high dose Loperamide?

A

Cardiac effects such as QT prolongation

69
Q

In regards to stoma use, why are patients on PPIs or H2 antagonists, somatostatin analogues?

A

Reduce gastric acid secretion and hence reducing stoma output

70
Q

What is the risk of patients consuming hypotonic fluids orally?

A

Not absorbed and then pass straight through into the stoma bag causing dehydration and loss of sodium.

71
Q

Which hypotonic fluids should patients with a stoma restrict?

A

Squash, tea to 0.5- 1L in 24hrs

Any losses replaced with oral rehydration solution such as St. Mark’s solution, Dioralyte

72
Q

What are the effects of the different salts?

A

Magnesium - causes diarrhoea
Aluminium - causes constipation

Ultimately effects stoma output

73
Q

What is the risk of diuretic use for patients with stomas?

A

Patients with stomas are at an increased risk of hypokalaemia and diuretic use may exacerbate this.

If patient is taking digoxin, hypokalaemia increases the risk of toxicity

74
Q

What is the effect of taking iron preparations in stoma patients?

A

Causes sore skin (use IV)
Causes constipation / diarrhoea

75
Q

In patients with Ileostomies can you use laxatives?

A

No due to risk of dehydration

76
Q

In patients with colostomies can you use laxatives?

A

Use non-pharmacological therapies first for constipation
Then use bulk forming such as Ispaghula husk then stimulant laxative (very small dose)

77
Q

What other considerations should be made for stoma patients?

A

Avoiding any substances which can cause constipation or diarrhoea (Sorbitol)

78
Q

What are the key pain management strategies in IBD?

A

Avoid opioid use due to poor outcomes and dependence
When opioids are used - just short-term and low doses
Consider other options - antidepressants or other analgesics
Rule out abscesses, inflammation and strictures

79
Q

What other conditions are IBD patients at risk of?

A

Anxiety or depression
VTE- at an increased risk, must receive prophylaxis whilst in hospital

80
Q

When is pain experienced with IBD?

A

Anytime even in the absence of inflammation and symptoms

More common in women.

Lower gastro-intestinal diseases (15 decks)

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