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Exam 1- GI and CVD > Ulcerative collitis > Flashcards

Ulcerative collitis Flashcards

1
Q

What is UC?

A

Mucosal inflammation of the colon- starting in the rectum and extending continuously in the colon.

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2
Q

What are the symptoms of UC?

A
  • Recurring diarrhoea that may contain blood or mucus
  • Cramping and stomach pain
  • Urgency to defecate
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3
Q

What percentage of patients often need surgery 10 years from diagnosis?

A

15-20%

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4
Q

What are the types of surgery that UC patients may have?

A
  • Sub-total colectomy : removal of colon
  • Procto-colectomy: Entire removal of colon, rectum and anal canal
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5
Q

What are the aims of therapy for UC patients?

A
  • Decrease symptoms
  • Increase quality of life
  • Induce and maintain remission
  • Minimize drug-associated toxicity
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6
Q

What does the Montreal classification classify a patients UC based on?

A

The extent and severity of the disease

E1= proctitis
E2= Left-sided
E3= Extensive

Severity
S0= Clinical remission = asymptomaic
S1= Mild = 4 or less stools +/- blood, no systemic illness, normal inflammatory markers
S2= Moderate= greater than 4 stools, minimal signs of systemic toxicity
S3= Severe= 6+ stools, pulse = 90+ bpm, increased temp 37.5 degrees + , decrease in haemoglobin, increased ESR

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7
Q

What factors influence the choice of therapy given to UC patients?

A
  • Severity - NICE
  • Extent
  • Disease location - NICE
  • Previous response to therapy
  • Presence of complications
  • Risk factors- patient charateristics, risks vs benefit, cost
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8
Q

On diagnosis, what percentage of patients have proctitis?

A

30-60%

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9
Q

On diagnosis, what percentage of patients have left-sided colitis?

A

16-45%

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10
Q

On diagnosis, what percentage of patients have extensive pancreatitis?

A

14-35%

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11
Q

What is proctitis?

A

Inflammation of the lining of the rectum

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12
Q

According to NICE guidelines, what is the recommended induction therapy for mild-moderate UC specifically affecting the rectum (Proctitis)?

A

1st line: Topical aminosalicylate
- Preferably suppositories as they deliver directly to the rectum (Enemas deliver further up and so pool in the sigmoid)
- If remission is not achieved in 4 weeks, add an oral aminosalicylate
- If this is still insufficient, consider topical or oral corticosteroids- short-term use only!
e.g. oral prednisolone 40mg OD for 6-8 weeks or Prednisolone 5mg suppository OD

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13
Q

What is more effective in mild-moderate proctitis, oral or topical aminosalicyclate?

A

TOPICAL!
But patients offer decline suppositories

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14
Q

According to NICE guidelines, what is recommended for inducing remission in mild-moderate UC (proctosigmoiditis + left-sided colitis)?

A
  • Topical aminosalicylate- as the condition has moved to the sigmoidal /distal area, an enema is preferred- 1g per day
  • If remission has not been achieved within 4 weeks:
  • Add a high dose oral salicylate- 2/3g per day
  • Or switch to high-dose oral aminosalicylate AND time-limited topical corticosteroid
  • If still inefficient- Stop topical treatment and offer oral aminosalicylate and time-limited oral corticosteroid
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15
Q

According to NICE guidelines, what is recommended for inducing remission in mild-moderate extensive colitis?

A

Topical aminosalicylate and high-dose oral aminosalicylate
- If remission is not achieved in 4 weeks, stop topical treatment and offer time-limited course of corticosteroids

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16
Q

According to NICE guidelines, what is the recommended therapy for inducing remission in moderate-severe UC?

A

Oral corticosteroid e.g. Prednisolone 40-60mg OD- given as a single daily dose as it has the same effectiveness as dividing the doses but dividing increases the risk of adrenal suppression
- If conventional therapies are inadequate- can use biological agents and Janus kinases e.g. Infliximab, adalimumab, golimumab,

17
Q

Why are daily doses of steroids not divided into multiple doses?

A

Because it has the same therapeutic effects
- but dividing the doses increases the risk of adrenal suppression

18
Q

In what order are the biological agents and janus kinases used in moderate-severe UC, where conventional therapy is inadequate?

A

Monoclonal antibodies- infliximab, adalimumab, golimumab, are used if conventional therapies are inadequate
- Vedolizumab is used if inadequate response to conventional therapy or TNF antagonists
- Tofacitinib is used when conventional therapies or biologic therpay is inadequate or lost

19
Q

What treatment is given to induce remission in acute severe cases of uc?

A

Patients should be hospitalised:
- Give IV corticosteroids e.g. Methylprednisolone 60mg/day or hydrocortisone 100mg QDS
- If steroids don’t show a response within 72 hours- consider adding iv ciclosporin
- if ciclosporin is clinically inappropriate, add infliximab

If steroids are contraindicated/intolerant, consider:
- IV ciclosporin
- Surgery

  • Assess the likelihood of needing surgery

also
IV fluids
electrolyte imbalance
stool cultures
vte prophylaxis
nutrients support

20
Q

What criteria is recommended by NICE to determine whether patients have severe uc?

A

Patients are assessed against Truelove and Witts criteria:
- 6+ bloody stools per day
And at least one of:
high temp (37.8 +)
Pulse 90 bpm+
Haemoglobin less than 105g/L
CRP 30mg/L +

21
Q

If IV corticosteroids don’t show a response within 72 hours in severe hospitalised cases, what is the next step?

A

Consider adding IV Ciclosporin

22
Q

If Ciclosporin is inappropriate for a patient, what is the add-on therapy to corticosteroids in severe hospitalised UC cases?

A

Can use Infliximab

23
Q

What is the recommended treatment for maintaining remission in mild-moderate proctitis/proctosigmoiditis?

A

Topical aminosalicyclates alone
- either daily
- or intermittently- when noticing flares

  • Or oral aminosalicylates and topical aminosalicyclates
  • Oral aminosalicylates alone - tell the patient that isn’t as effective as topical or combined
24
Q

What is the recommended treatment for maintaining remission in mild-moderate left-sided and extensive uc?

A

Low maintenance dose oral aminosalicyclate

25
Q

When may the use of mercaptopurine or azathioprine be considered for maintaining remission?

A

If:
- Had 2+ inflammatory exacerbations in 12 months that have required systemic steroids
OR
- Remission not maintained by aminosalicylates

26
Q

If remission is not maintained by aminosalicylates, what other drugs may be used?

A

Mercaptopurine or Azathioprine

27
Q

What drugs are aminosalicyclates?

A

Mesalazine
Olsalazine
Sulphasalazine
Balsalazide

Exam 1- GI and CVD (43 decks)

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