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Fall 2024 > Therapeutics Exam 4 (Inflammatory Bowel Disease) > Flashcards

Therapeutics Exam 4 (Inflammatory Bowel Disease) Flashcards

1
Q

What 2 disease states make up Irritable Bowel Disease (IBD)?

A

Ulcerative Colitis

Crohn’s Disease

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2
Q

What parts of the body are affected by Ulcerative Colitis (UC)?

A

Rectum and Colon

-mucosal + submucosal inflammation (more superficial)
-only affects the lower GI tract

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3
Q

What parts of the body are affected by Crohn’s Disease (CD)?

A

Any part of the GI tract from the mouth to the anus

-Transmural inflammation of any part of the GI tract
-Terminal ileum is most common
-CD normally affects tissue deeper than UC

*Rectal involvement is uncommon
*Perianal disease is common

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4
Q

What physical appearance specific to Crohn’s disease can help differentiate it from other conditions?

A

Crohn’s disease appears as discontinuous segments of infected bowel with normal bowel separating it

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5
Q

What effect does smoking have on ulcerative colitis?

A

Potentially protective

-reduced disease activity, fewer flare-ups

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6
Q

What effect does smoking have on Crohn’s disease?

A

Increases severity

-increased disease frequency and severity

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7
Q

**What is the main drug class that can trigger IBD?

A

NSAIDs!!!!

patients need to avoid these
-may trigger disease occurrence or lead to flares

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8
Q

Which drug class has a potential association with triggering IBD?

A

Antibiotics

*causal relationship is unclear

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9
Q

What are the 2 main symptoms of ulcerative colitis?

A

Diarrhea + Bleeding

-due to mucosal damage and friability

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10
Q

What life-threatening complications are we concerned about with UC?

A

Toxic Megacolon

Colonic dysplasia/Colorectal cancer (CRC)

note that fistulas and strictures are UNCOMMON

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11
Q

What are the defining features of toxic megacolon?

A

Severe and potentially fatal complication of UC

-Segmental or total colonic distention (>6cm)
-Acute colitis
-Signs of systemic toxicity

*50% mortality

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12
Q

What complications are we concerned about with Crohn’s disease?

A

Small bowel stricture

Obstruction

Fistula formation is common

Less bleeding is seen than with UC but anemia is still possible

Carcinoma, but not as likely as with UC

Nutritional deficiency

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13
Q

What is a fistula?

A

A connection between 2 areas that should not be connected in the body

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14
Q

Which laboratory test for UC correlates with the degree of inflammation present?

A

Fecal Calprotectin (FC)

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15
Q

How is UC diagnosed?

A

-Clinical suspicion

-Confirmed by endoscopy (colonoscopy or sigmoidoscopy) and biopsy

-Negative stool examination for infectious causes (Cdiff)

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16
Q

What is hematochezia?

A

Blood in stool

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17
Q

True or False: IBD can be cured

A

False, no medications are curative

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18
Q

What are the drug classes used in IBD treatment?

A

ASAs (aminosalicylates)
Corticosteroids
Immunomodulators (suppressives)
Biologics
Antimicrobials

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19
Q

What drugs are considered aminosalicylates (ASA)?

A

Sulfasalazine
Mesalamine (5-ASA)

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20
Q

What drugs are considered immunomodulators (immunosuppressives)?

A

Azathioprine
Mercaptopurine (MP)
Cyclosporine
Methotrexate

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21
Q

What are the two categories of biologics?

A

Anti-TNF-a

Other

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22
Q

What are the Anti-TNF-a drugs?

A

Infliximab
Adalimumab
Certolizumab
Golimumab

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23
Q

What are the other biologic drugs?

A

Natalizumab
Vedolizumab
Ustekinumab

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24
Q

What are the antimicrobial drugs?

A

Metronidazole
Ciprofloxacin

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25
Q

What are the 2 components of sulfasalazine?

A

Sulfapyridine + Mesalamine (5-ASA)

-5-ASA is the active compound
-Sulfapyridine is associated with ADR’s!

26
Q

If sulfapyridine causes ADR’s then why do we not just give mesalamine alone?

A

We can!

-But it is very rapidly absorbed in the small intestine and giving it alone prevents it from staying in the lumen where it is needed
-But we can use local forms like: enemas, suppositories, or delayed release forms

27
Q

What area is involved in proctitis UC?

A

Rectal area

28
Q

What area is involved in pancolitis UC?

A

Majority of colon

29
Q

Which drug form works best for proctitis?

A

Suppository

30
Q

Which drug form works best for left-sided disease?

A

Enema

31
Q

Which drug form works best for extensive disease + pancolitis?

A

Systemic tx

32
Q

What is therapeutic drug monitoring used for?

A

To determine drug and anti-drug antibody concentrations

33
Q

What drugs have the most data for therapeutic drug monitoring?

A

Infliximab
Adalimumab

34
Q

When should we consider doing therapeutic drug monitoring?

A

If there is a loss of treatment response

-This monitoring is done reactively, we do not check it to see how the patient is doing

35
Q

If a patient undergoes Therapeutic Drug Monitoring and has Detectable Antibodies + Sub-Therapeutic Drug Levels, what do we do?

A

Change to alternate drug in the SAME class +/- immunomodulator

-This is an immune mediated pharmacokinetic failure
-We can still keep the patient on the same drug class especially if they had a good initial response to the original drug

36
Q

If a patient undergoes Therapeutic Drug Monitoring and has Detectable Antibodies + Therapeutic Drug Levels, what do we do?

A

Repeat the levels to check for false positive

Switch to a biologic from a different drug class

37
Q

If a patient undergoes Therapeutic Drug Monitoring and has No Antibodies with Sub-Therapeutic Drug Levels what do we do?

A

Escalate the dose

38
Q

If a patient undergoes Therapeutic Drug Monitoring and has No Antibodies with Therapeutic Drug Levels but no response what do we do?

A

Switch to a biologic from another class

-The patient is just not responding to the drug for an unknown reason
-If they do not respond to one, they probably will not respond to another in the same class

39
Q

For mild-moderate active UC, if the patient has extensive disease what do we use as first-line therapy?

A

Oral 5-ASA

Sulfasalazine
Mesalamine

40
Q

For mild-moderate active UV, if the patient has left sided disease what do we use as first-line therapy?

A

5-ASA enema

-topical mesalamine enema

41
Q

For mild-moderate active UV, if the patient has proctitis what do we use as first-line therapy?

A

5-ASA suppository

-mesalamine suppository

42
Q

When may a combination of oral and topical options for UC be more effective?

A

Pts with left-sided/extensive disease

43
Q

Which monotherapy works better: topical or oral?

A

Topical typically

44
Q

If a patient is unresponsive to 5-ASA, what is the next step?

A

Consider changing the dosage form

45
Q

If a patient is unresponsive to standard-dose 5-ASA or continues having moderate disease activity, what is the next step?

A

High dose mesalamine (>3g/day) + Rectal Mesalamine

(combo therapy)

46
Q

If a patient with mild-moderate UC is refractory to ASA’s what is the next step?

A

PO corticosteroids

-Budesonide
-Prednisone

47
Q

Budesonide usage should be limited to what?

A

<8-16 weeks

48
Q

When are topical corticosteroids an option? (foams, enemas, suppository)

A

Distal disease
(ex: left sided, proctitis)

49
Q

For moderate UC, besides mesalamine, what is the other potential first line option?

A

PO Controlled Release Budesonide

50
Q

True or False: 5-ASA therapy is the first-line option for severe UC

A

No, it is probably not going to be effective

51
Q

What is the first-line therapy for Severe UC?

A

Systemic corticosteroids

(po prednisone)

-consider TNF-a inhibitors/biologics

52
Q

True or False: we should continue 5-ASA therapy in moderate-severe UC patients who achieve remission with biologics/immunosuppressants

A

FALSE
-do not continue 5-ASA as induction or maintenance in these pts

53
Q

What are the first-line options for severe UC treatment?

A

Option 1:
-Budesonide or Prednisone

Option 2 (Treatment Naive):
-Prednisone + Infliximab or Vedolizumab +/- Azathioprine

Option 3 (Previous infliximab exposure):
Ustekinumab to Tofacitinib

54
Q

What are the first-line treatment options for severe-fulminant UC?

A

Parenteral Corticosteroids
-methylprednisolone
-hydrocortisone
(IV then po)

Consider TNF-a Inhibitors
-infliximab

Consider cyclosporine or infliximab in pts unresponsive to IV steroids

55
Q

What drugs should be used for maintenance of remission for UC?

A

ASA

TNF-a antagonist (infliximab/adalimumab)

Patients who are steroid dependent:
-Azathioprine
-6-MP

-make choice based on what patient has already been started on

56
Q

Which drug class should not be used to maintain remission in UC?

A

Corticosteroids

57
Q

What is the first-line therapy for mild-moderate CD?

A

Sulfasalazine

-mesalamine has no efficacy
-these drugs do not work super well

58
Q

What is the first-line therapy for moderate-severe CD?

A

Systemic corticosteroids
(po prednisone)
-may be more effective than budesonide

If hospitalized:
-IV corticosteroids
(methylprednisolone, hydrocortisone)

Early biologic therapy may be useful
(TNF-a inhibitors)
(combo therapy of infliximab or adalimumab + AZA may be more effective)

59
Q

What treatment options should we use for severe/fulminant CD?

A

Parenteral corticosteroids (if no abscess)
-methylprednisolone
-hydrocortisone

Consider infliximab or other biologic if not already attempted

60
Q

What drug may be preferred for fulminant CD?

A

Infliximab

-last option before surgery

61
Q

What drugs can we use for maintenance of remission with CD?

A

AZA and 6-MP

Methotrexate

TNF-a Antagonists

Vedolizumab, Ustekinumab, Risankizumab

Fall 2024 (16 decks)

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