Treatment of Inflammatory Bowel Disease Flashcards
Two dermopathies associated with inflammatory bowel disease
Pyoderma gangrenosim
Pyoderma nodosum
Mouth features in IBD
Oral facial granulomatous
Steroids for flare ups
Glucocorticoids
- Iv hydrocortisone, methylprednisolone for hospital admissions
- oral prednisolone - home
Rapidly induction of remission
Slow reducing course
- prednisolone 40mg daily/1 week
- reduce by 5mg/week
Side effects of steroids
- immunosuppresion
- impaired glucose tolerance
- osteoporosis
- weight gain
- cushingoid appearances
Aminosalicylates (5-asa)
- anti-inflammatory
- ph dependent release/resin coated (Asacol)
- time controlled release (pentasa)
- Deliver by carrier therapys
Main role of aminosalicylates
- maintenance of remission in UC
- efficacy more related to complicance than delivery system
- maintenace therapy may reducer cancer risk
- little evidence to support use in crohn’s
Side affects of aminosalicylates
Sulphasalazine 10-45%
Mesalazine intolerance 15%
- renal impairement (interstial nephritis ) is rare
- diarrhoea, nausea, rarely pancreatitis, bone marrow problems
Thiopurines
Azathioprine and mercaptopurine (mercaptopurine is the active metabolite) however more expensive
-effective in active and maintenance therapy for UC and Crohns
Steroid sparing agent:
- those requiring 2+ course steroids in a year
- relapse on
Thiopurine mechanism of action
- purine anti-metabolytes
- essentially prevent T cell clonal expansion in response to antigenic stimuli
- allow T cell apoptosis
Thiopurine dosing
Dose dependent on weight
- 1.5mg/kg/day azathioprine
- 1-1.5mg/kg/day mercaptopurine
Monitoring (overly immunosuppresion)
-weeekly FBC for 8/53 then at least every 3/12
Side effects of thiopurines
- nause, vomitting
- leucopenia
- arthlagia
- pancreatitis
- hepatitis
Main enzyme for metabolising mecaptopurine
TPMT
- thipurine methytransferase
- genetically determined
- absent/low/normal activity
- predicts bone marrow suppression
- checked prior to starting
Dosing of thipurines
checked with active metabolites
6-TGN
- Active metabolite of thipurines
- measurement allows dose escalation
- also identifies non-compliance
meMP
- metabolitie associated with hepatotoxicity
- allows dose reduction to minisime risk
Give allopurinal + mecatopurine in low doses to even out levels of metabolities
Methotrexate
- anti-metabolities
- folate scavenger- need folate supplements
- 15-25mg weekly
- effective in crohns
- little evidence in UC
- widely used in inflammatory disease
- serious teratogenicity
Adverse affects of methotrexate
- highly teratogenic
- hepatotoxic -liver fibrosis
- pulmonary fibrosis
- nausea, malaise, GI upset
Biologics
Infiximab
- murine anti-TNF-alpha monoclonal antibody
- severe or fistulating corhns
- some beenefit in acute severe UC
- 2 monthly intravenous infusion
- loss of efficacy
- allergic reactions
- expensive
Adalumimab
- humanised anti-TNF alpha monoclonal antibod
- fortnightly SC injections
- less reaction
- less need for concomitant immunospurresion
- arginally less expensive
Acute severe colitis
patients who fail to respond o to optimal treatment
- IV steroids
- Liaison with colorectal surgeon
- stool frequency ?8/day/CRP >45 on day 3 predicts colectomy in 85%
Criteria for acute severe colitis
Truelove & Witts
Spilt into mild and severe
Bms/day Pr blood Temperatire Pulse Hb ESR
Acute severe collitis investifations
Daily FBC, ESR, U&Es, CRP
- stool cultures (including C.difficile)
- daily AXR
- Sigmoidoscopy
Treatment for acute severe collitis
Prophylactic LMW heparin
IV hyrdrocortisone 100mg QDS
Treat for 72 hours
- -improving then oral prednisiole-40mg
- no improvement - rescue therapy
Rescue therapy for acute severe colitis
Ciclosporin 2.g/kg/day IV
Infliximab 5mg/kg single dose
Surgery
If medical therapy doesnt work then surgery indicated
Surgery for UC and Crohns
UC
- surgery curative
- ileo-anal pouch or ileostomy
Crohns
- indicated for stricturing, perforation, fistulising disease
- sparing as will come back
- not curative
