Ulcerative colitis

Question 1

what are the characteristics of ulcerative colitis and what age does it commonly present?

Answer 1

1) Chronic inflammatory condition, characterised by diffuse mucosal inflammation. The pattern of inflammation is continuous, extending from the rectum upwards to a varying degree
2) Commonly presents between the ages of 15 and 25

Question 2

list the common symptoms of active disease or relapse (3)

Answer 2

1) Bloody diarrhoea
2) Urgent need to defaecate
3) Abdominal pain

Question 3

what are the complications associated with ulcerative colitis?

Answer 3

1) Increased risk of colorectal cancer
2) Secondary osteoporosis
3) Venous thromboembolism
4) Toxic megacolon

Question 4

What tool is used to assess the severity of UC and what factors does it take into consideration?

Answer 4

Truelove and Witts' Severity Index:
1) Assess bowel movements
2) Heart rate
3) Erythrocyte sedimentation rate
4 Presence of pyrexia
5) Presence of melaena 
6) Presence of anaemia

Question 5

In UC the extent of disease should be considered when choosing the route of administration. what type of formulation would be suitable for the following?

1) Inflammation is distal
2) inflammation is extended

Answer 5

1) If the inflammation is distal, a rectal preparation

2) Inflammation is extended, systemic medication is required

Question 6

what preparations can be used when patients have difficulty retaining liquid enemas

Answer 6

Rectal foam preparations and suppositories

Question 7

How is diarrhoea associated with ulcerative colitis treated and why should these drugs not be used in an acute attack of UC?

Answer 7

1) On advice of specialist: Anti-diarrhoeal drugs- loperamide or codeine
2) Increase the risk of toxic megacolon

Question 8

what is the difference between proctitis and proctosigmoiditis

Answer 8

1) Proctitis: Inflammation of the rectum

2) proctosigmoiditis: inflammation of the rectum and sigmoid colon

Question 9

Which drug can be used for proximal faecal loading (faecal matter accumulates) in proctitis

Answer 9

A macrogol-containing osmotic laxative

Question 10

Why are single daily doses of oral aminosalicylates recommended for maintaining UC and what is the disadvantage?

Answer 10

Single daily doses can be more effective than multiple daily dosing, but may result in more side-effects

Question 11

what is the benefit of giving oral and rectal aminosalicylates for the treatment of mild-to-moderate UC

Answer 11

Oral and rectal aminosalicylates in combination can be used as first line treatment in patients and this results in higher rates of improvement

Question 12

Outline the treatment of mild-to-moderate Proctitis and proctosigmoiditis

Answer 12

1) Aminosalicylates first-line- Rectal mesalazine or sulfasalazine alone are effective
↳Monotherapy with an oral aminosalicylate considered for patients who prefer not to use enemas or suppositories but not as effective.
2) A rectal corticosteroid (budesonide, hydrocortisone or prednisolone) or oral prednisolone if intolerant to aminosalicylates.

Question 13

Outline the first line treatment for left-sided or extensive ulcerative colitis

Answer 13

1) High induction dose of an oral aminosalicylate, with addition of a rectal aminosalicylate or oral beclometasone dipropionate if necessary.
2) if above C/I consider oral prednisolone alone

Question 14

How should Initial treatment failure in all extents of mild-to-moderate ulcerative colitis be managed?

Answer 14

1) If no improvement with an aminosalicylate within 4 weeks or if symptoms worsen consider adding oral prednisolone
2) If no response after 2-4 weeks consider adding oral
tacrolimus [unlic] to induce remission

Question 15

Outline the treatment of acute severe ulcerative colitis

Answer 15

1) IV corticosteroids (e.g. hydrocortisone or methylprednisolone) to induce remission, while assessing need for surgery
↳If above C/I or not tolerated: IV ciclosporin [unlic] or surgery should be considered
2) IV ciclosporin + IV corticosteroids, or surgery is second line therapy for patients with no improvement within 72 hours of starting intravenous corticosteroids

Question 16

which monoclonal antibody has been shown to be as effective as ciclosporin for the treatment of acute ulcerative colitis?

Answer 16

Infliximab- can be used to treat acute exacerbations of severely active ulcerative colitis if ciclosporin C/I or clinically inappropriate

Question 17

1) To reduce the chances of relapse , maintenance therapy is recommended in ulcerative colitis. Which drug is used in maintenance therapy in most patients?
2) which drug should not be used for maintenance?

Answer 17

1) maintenance therapy with an aminosalicylate is recommended
2) Corticosteroids are not suitable for maintenance treatment because of their side-effects

Question 18

Describe the maintenance treatment that should follow after a mild-to-moderate inflammatory exacerbation of proctitis or proctosigmoiditis

Answer 18

A rectal aminosalicylate alone or in combination with an oral aminosalicylate taken daily or as part of an intermittent regimen (e.g. twice to three times weekly or the first seven days of each month)

Question 19

outline the maintenance treatment for patients after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis.

Answer 19

low-dose of oral aminosalicylate is given to maintain remission

Question 20

when can oral azathioprine or mercaptopurine be considered to maintain remission?

Answer 20

1) two or more inflammatory exacerbations in a 12-month period that required treatment with systemic corticosteroids, or
2) If remission is not maintained by aminosalicylates, or
3) Following a single acute severe episode

Question 21

Can monoclonal antibodies be used for maintaining remission of ulcerative colitis?

Answer 21

1) if effective and tolerated in acute disease, treatment with these agents is continued into the maintenance
2) Vedolizumab- used in moderate to severe UC and crohns, in those who are unsuccessful with conventional therapy ( causes hypersensitivity reactions- monitor)

Question 22

name two corticosteroids used in ulcerative colitis

Answer 22

1) Beclometasone Dipropionate tablets

2) Budesonide ( also used in crohns)