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IPFC 5 > Ulcerative Colitis and Crohn's Therapeutics > Flashcards

Ulcerative Colitis and Crohn's Therapeutics Flashcards

1
Q

What is the treatment for Mild UC
Dose
Duration

A

Mesalamine (5-ASA)

Induction: 3g daily by mouth
+ 1g once-twice/day rectally (ideally combo, especially if lower GI)

Maintenance: 2-3g daily by mouth
+/- 1g daily rectally

Duration
- 1-2 weeks for improvement, 4-6 weeks for remission

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2
Q

MOA of sulfasalazine

A

sulfapyridine + Mesalamine:
to prevent absorption of mesalamine (5-ASA) UNTIL it reaches site of action (colon)

Mesalamine is preferred

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3
Q

When is combo of oral and rectal mesalamine used in mild UC?

A
  • Active left sided UC
  • extensive UC
  • Proctitis (lower part of GI)
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4
Q

What are Adverse effects of aminosalicylates (5)

A

Generally well-tolerated

Headache
Loss of appetite
Nausea/vomiting
Rash
Hair loss

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5
Q

When are corticosteroids used in mild treatment of UC?
What are the options?

A

Used when symptoms of UC has not improved after 4 weeks of 5-ASA

  • Hydrocortisone once-twice/daily rectally via suppositories, foams, enemas
  • Budesonide 9mg by mouth daily
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6
Q

Which biologics have conditional recommendation and not strong recommendation in UC (3)

A

Adalimumab
Mirikizumab
Fligotinib

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7
Q

What is the treatment for moderate-severe UC?

A

Do not use 5-ASAs
Go straight to anti-TNF agents + immunomodulator therapies

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8
Q

Which Ant-tnfs are used in UC (3)

A
  1. Infliximab (REMICADE) IV @ 0, 2, 6 weeks, then SC q2weeks
  2. Golimumab (SIMPONI) SC @ 0, 2 weeks, then SC q4weeks
  3. Adalimumab SC @ 0, 2 weeks, then SC q2weeks
    - lower efficacy
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9
Q

Which immunomodulators can be added to anti-tnf (2)

A
  1. Azathioprine 50-100mg daily
  2. Mercaptopurine 25-50mg daily
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10
Q

What are adverse effects of anti-TNFa (8)

A
  • Infusion reactions (for infliximab),
  • headache
  • rash
  • infection
  • reactivation of TB/Hep B
  • cancer
  • cardiac failure
  • demyelination
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11
Q

What are the adverse effects of azathioprene and mercaptopurine (3) interactions (2)

A

ADRs
- bone marrow suppression
- infection
- GI toxicity

Interactions
- live vaccine limitations
- interacts with allopurinol

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12
Q

Which monoclonal antibody is used in UC and CD? Monitor for remission for how long?

A

Vedolizumab (ENTYVIO) IV @ 0, 2, 6 weeks, then SC q2weeks
Monitor for remission in 8-14 weeks

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13
Q

What are the more common AE reports in vedolizumab (entyvio) in clinical trials (2)

A

Nasopharyngitis
Headache

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14
Q

What are the IL-12/23 inhibitors used in UC and CD (3)

A
  1. Ustekinumab (STELARA) IV x1, then SC q8weeks
    - both IL12/23
  2. Risankizumab (SKYRIZI) IV @ 0, 4, 8 weeks, then SC q8weeks
    - IL-23 only
    - higher efficacy
  3. Mirikizumab IV @ 0, 4, 8 weeks, then SC q4weeks
    - IL-23 only
    - not as effective
    - only for UC- not studied in CD
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15
Q

What are AEs for ustekinumab (3)

A
  • Nasopharyngitis
  • Headache
  • opportunistic infections
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16
Q

What are the AEs for risankizumab and mirikizumab (2)

A

Similar to ustekinumab
- higher incidence of pain and redness at injection site
- lower risk of infection since it only targets IL-23

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17
Q

Which JAK inhibitors can be used in UC and CD

A

Upadacitinib 45mg daily x8 weeks, then 15mg daily
- JAK-1 only

Tofacitinib 10mg BID x8 weeks, then 5mg BID
- JAK-1,3 and to a lesser extent 2
- not used in CD

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18
Q

What are the adverse effects of the JAK inhibitors (5)

A
  • High lipids
  • CV events
  • cancer
  • clots
  • infection
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19
Q

Which S1P inhibitors (PO) are used for UC (2)

A
  1. Ozanimod
  2. Etrasimod
20
Q

What are adverse effects of Ozanimod? (5) Considerations?

A
  • Bradyarrhythmia
  • AV conduction delys
  • elevated LFTs
  • Infection
  • malignancy

Consider
- after failure of TNFa
- Baseline ECG required

21
Q

What are adverse effects of Etrasimod? Reasoning?

A

Only blocks S1P4
- Fewer cardiac events
- More GI adverse effects (diarrhea, cramping)

22
Q

With patients who have tried an anti-TNF before and was ineffective Which medications are higher efficacy (3)
which medications are lower efficacy (4)

A

Higher efficacy:
- Tofacitinib
- upacitinib
- ustekimunab (stelara)

Lower efficacy
- Adalimumab
- vedolizumab
- ozanimod
- Etrasimod

23
Q

What is the treatment for severe and acute UC treatment? if responding?
eg. patient has bleeding, severe systemic disturbances

A

IV corticosteroids (16mg methylprednisolone q8h, hydrocortisone 100mg q8h) for 3-5 days

If responding, can step down to Prednisone 60mg daily, then taper. Start typical treatment.

24
Q

What do you if there is no response to IV corticosteroids in UC? duration to monitor?

A

If not responding in 3-5 days
ADD ON
- infliximab 5mg/kg induction dose (wk 0,2,6) then maintenance OR
- cyclosporine

25
Q

What happens if no improvement of infliximab? Duration to monitor?

A

Repeat at double dose if no response within 5 days of the 5mg/kg

26
Q

Considerations when giving cyclosporine? (3)
Adverse effect? (6)

A
  • Have to be given with azathioprene or mercaptopurine (for bridging)
  • need to check levels <300ng/mL for therapeutic trough
  • add PJP prophylaxis (sulfatrim to avoid pneumonia)

AE
- Opportunistic infections
- vasoconstriction, hypertension
- kidney damage
- liver damage
- seizure
- unwanted hair growth

27
Q

What happens if severe UC patient is responding to
Glucocorticoids
Infliximab
Cyclosporine

A

Glucocorticoids
- step down to 60mg prednsione pod aily and taper
- initiate anti-TNFa agent +/- imunosuppresant

Infliximab
- continue infliximab and add immunosuppresent for 6 months

Cyclosporine
- transition to oral cyclosporine
- taper off steroids
- PJP prophylaxis recommended (sulfatrim)
- maintain on monotherapy

28
Q

What are higher efficacy in naive UC patients? (7) What are lower efficacy? (1)

A

Higher:
- Infliximab
- Verdolizumab
- Risankizumab
- Upacitinib
- Ozanimod
- Estrasimod

29
Q

Which drugs can we not use with CD that we use with UC? (4)

A
  • No 5-ASA
  • No cyclosporine
  • No tofacitinib
  • No S1P drugs
30
Q

What is the treatment for Mild Crohn’s disease
(2)

A

Left-sided colon
- Prednisone 40-60mg/day 2-4weeks, then taper

Right sided colon/terminal ileum
- Budesonide 9mg daily x4-8 weeks, then taper

31
Q

What to do if no improvement of mild CD?

A

If no improvement, then treat as moderate-severe CD

32
Q

What is the difference between Anti-TNFa agents used in UC and CD? Similarity?

A

Similarity
- used in combo with thiopurines (azathioprene, mercaptopurine)

Difference
- adalimumab is equally effective

33
Q

When is methotrexate used in Crohn’s? Considerations?

A

Used in high risk or steroid refractory cases

25mg weekly induction
15mg weekly maintenance

Supplement with folic acid 1mg daily or 5mg weekly

34
Q

What are the adverse effects of methotrexate (4)

A
  • Hair loss
  • nausea
  • bone marrow suppression
  • liver toxicity
35
Q

What is the treatment for Fistulizing Crohn (2 options)

A

Same treatment as non-fistulizing
add on:
1. Metronidazole 500mg BID + cipro 500mg BID
(cover gram negative and anaerobes)

Surgical management and drainage of abcess may be indicated if patients become septic (red, inflamed fistulas, chills, fever)

36
Q

What are the 2 reasons CD patients are hospitalized? What are the symptoms associated with it?

A

Bowel OBSTRUCTION secondary to stricture
- N/V, cramping, inability to pass stool

Abscesses/infection due to FISTULIZING disease
- fever, chills, leukocytosis, right lower quadrant pain

37
Q

What is the treatment for hospitilized partial bowel obstruction (3 lines of treatment)

A
  1. Medication management
    - NPO, parenteral nutrition, hydration
    - no oral meds
  2. IV corticosteroids (16mg methylprednisolonve IV q8h)
  3. Surgical consult
38
Q

What is the treatment for hospitalized of abscess/localized peritonitis

A

Antibiotics and drainage
Usually quinolone or 3rd gen cephalosporin + MTN

39
Q

T/F we can use NSAIDs in IBD
Why?

A

False
- inhibits prostaglandin synthesis and may impair mucosal barrier

40
Q

What is toxic megacolon?
Risk factors? (5)

A

Segmental, non-obstructive colonic dilation with systemic toxicity
- high risk of perforation

Precipitated:
- Hypokalemia
- Anti motility agents
- Opioids
- Anticholinergics
- Colonoscopy (stretching/thinning of gut)

41
Q

How is toxic megacolon diagnosed

A

Radiographic evidence of colonic dilatation (CT scan, x-ray)

3 of the following
- Fever 38+
- HR 120+
- High WBC count
- Anemia

Plus 1 of:
- Dehydration
- Altered sensorium (pt out of it)
- Hypotension

42
Q

What is the management of toxic megacolon (3)

A
  1. Complete bowel rest (complete NPO, IV hydration, IV meds etc..) (don’t need TPN)
  2. IV corticosteroids (100mg hydrocortisone q6-8h)
  3. Broad spectrum antibiotics (Cetriaxone + metronidazole)

If doesnt work possibly cyclosporine or infliximab
5-ASA not effective

43
Q

What drugs affect fertility in men? (2)

A

Sulfasalazine
Methotrexate

44
Q

If IBD patient has arthritis/arthralgias what can they use? (2) what can’t they use? (2)

A

Can’t use
- No opioids (slows gut motility, can cause toxic megacolon)
- No NSAIDs (can incite flares)

Can use
- topical agents
- short, low-dose steroid

45
Q

What is the reason for anemia in IBD

A

Blood loss from GI tract
May be related to Vit B12 or folic acid malabsorption

46
Q

What is the treatment of episcleritis/uvetitis? When is it worse

A

Worse during flare-ups

Treatment
- topical corticosteroid drops
- cool compresses

IPFC 5 (10 decks)

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