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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
What happens if no improvement of infliximab? Duration to monitor?
Repeat at double dose if no response within 5 days of the 5mg/kg
26
Considerations when giving cyclosporine? (3) Adverse effect? (6)
- 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
What happens if severe UC patient is responding to Glucocorticoids Infliximab Cyclosporine
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
What are higher efficacy in naive UC patients? (7) What are lower efficacy? (1)
Higher: - Infliximab - Verdolizumab - Risankizumab - Upacitinib - Ozanimod - Estrasimod
29
Which drugs can we not use with CD that we use with UC? (4)
- No 5-ASA - No cyclosporine - No tofacitinib - No S1P drugs
30
What is the treatment for Mild Crohn's disease (2)
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
What to do if no improvement of mild CD?
If no improvement, then treat as moderate-severe CD
32
What is the difference between Anti-TNFa agents used in UC and CD? Similarity?
Similarity - used in combo with thiopurines (azathioprene, mercaptopurine) Difference - adalimumab is equally effective
33
When is methotrexate used in Crohn's? Considerations?
Used in high risk or steroid refractory cases 25mg weekly induction 15mg weekly maintenance Supplement with folic acid 1mg daily or 5mg weekly
34
What are the adverse effects of methotrexate (4)
- Hair loss - nausea - bone marrow suppression - liver toxicity
35
What is the treatment for Fistulizing Crohn (2 options)
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
What are the 2 reasons CD patients are hospitalized? What are the symptoms associated with it?
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
What is the treatment for hospitilized partial bowel obstruction (3 lines of treatment)
1. Medication management - NPO, parenteral nutrition, hydration - no oral meds 2. IV corticosteroids (16mg methylprednisolonve IV q8h) 3. Surgical consult
38
What is the treatment for hospitalized of abscess/localized peritonitis
Antibiotics and drainage Usually quinolone or 3rd gen cephalosporin + MTN
39
T/F we can use NSAIDs in IBD Why?
False - inhibits prostaglandin synthesis and may impair mucosal barrier
40
What is toxic megacolon? Risk factors? (5)
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
How is toxic megacolon diagnosed
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
What is the management of toxic megacolon (3)
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
What drugs affect fertility in men? (2)
Sulfasalazine Methotrexate
44
If IBD patient has arthritis/arthralgias what can they use? (2) what can't they use? (2)
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
What is the reason for anemia in IBD
Blood loss from GI tract May be related to Vit B12 or folic acid malabsorption
46
What is the treatment of episcleritis/uvetitis? When is it worse
Worse during flare-ups Treatment - topical corticosteroid drops - cool compresses

IPFC 5 (14 decks)

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