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### > Week 11: Ulcerative Colitis > Flashcards

Week 11: Ulcerative Colitis Flashcards

1
Q

Explain the main features of Crohn’s Disease. (2)

A

Involves distal ileum, proximal colon, can affect entire digestive tract.

Inflammation can go through entire bowel wall thickness.

‘Cobblestoning’ structure

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2
Q

Explain the main features of Ulcerative Colitis. (3)

A

Affects only the colon
Diffuse inflammation
Affects the colonic mucosa.

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3
Q

What are the general s/s of CD + UC? (7)

A

Ab. pain/cramping
Diarrhoea (+/- blood/mucus)
Urgency
Fever
Fatigue
Weight/Appetite loss
Mouth Sores

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4
Q

Give e.g. of extra-intestinal manifestations that can present in UC + CD. (6)

A

Skin, eyes, joints + liver inflammation:
- Ankylosing spondilitis (spine/hip joint)
- Arthritis
- Erythema nodosum (flushing skin/shin tenderness)
- Uveitis (eye inflammation)
- Aphthous ulcers (painful open ulcers)

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5
Q

What are the potential complications of both CD + UC? (7)

A

Increased risk of colon cancer.
Malnutrition
Anaemia
Medication risks (cancers, HPT, OP)
Blood clots
Primary Sclerosing Cholangitis

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6
Q

What are the potential complications of Crohn’s Disease? (3)

A

Bowel wall narrowing (obstruction/Fistulas)
Ulcers
Anal Fissures

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7
Q

What are the potential complications of Ulcerative Colitis? (2)

A

Perforated Colon
Toxic Megacolon

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8
Q

What are the risk factors of CD + UC? (5)

A

Age
Family Hx
Infection
Smoking
Medication

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9
Q

What are the main causes of CD + UC? (3)

A

Genetics
Environment
Autoimmune

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10
Q

Give e.g. of investigations taken place for diagnosing UC/CD. (6)

A

Examination + Hx taking
Colonoscopy/sigmoidoscopy - Biopsies
Stool Cultures
Ab. X-ray
Blood tests - anaemia/inflammation
Endoscopy

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11
Q

What are the differential diagnoses of CD/UC? (8)

A

Colorectal Cancer
Other forms of IBD/Colitis
Infection
Diverticular disease
IBS
Appendicitis
Ectopic Pregnancy
Pelvic Inflammatory Disease

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12
Q

Explain the main differences between CD + UC in terms of disease distribution, rectal involvement, type of inflammation, diarrhoea, pain
extra-intestinal symptoms and smokers. (14)

A

CD: Throughout GIT, Occasionally, Patchy/transmural, mild-severe, colicky can mimic appendicitis, yes, higher rates.

UC: In colon, usually, continuous/mucosal, mild-very severe, lower ab. discomfort, yes, lower rates.

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13
Q

What are the treatment aims for CD/UC? (2)

A

Heal inflammation and reduces symptoms during flare-up.

OR

Flare-up prevention

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14
Q

Explain the Truelove + Witt’s Severity Index including the following: bowel movement per day, blood in stools, pyrexia, pulse rate > 90bpm, Anaemia (<10g/100ml), ESR. (18)

A

Mild: < 4, No more than small amounts of blood, no, no, no, ≤30.

Moderate: 4-6, between mild + severe, no, no, no, ≤ 30

Severe: > 6 (+ one of the features of systemic upset), visible blood, yes, yes, yes, > 30.

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15
Q

Explain the inducing remission process for proctitis. (3)

A

Topical Aminosalicylate alone.
Consider adding oral aminosalicylate to topical agent.
Consider time-lited course of topical/oral CS.

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16
Q

Explain the inducing remission process for proctosigmoiditis + left-sided. (4)

A

1st line: Topical aminosalicylate

High-dose of oral aminosalicylate OR

Switch to high-dose oral aminosalicylate + time-limited course of topical CS.

If unable to tolerate aminosalicylates, consider time-limited topical/oral steroid.

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17
Q

Explain the inducing remission process for extensive disease. (2)

A

Topical aminosalicylate + high dose oral aminosalicylate.

Stop topical + give high dose oral aminosalicylate with time-limited course of oral CS.

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18
Q

Provide a brief summary of inducing remission of UC in mild to moderate disease. (12)

A

1st line: Aminosalicylates
- Topical (proctitis, proctosigmoiditis, left-sided disease) or oral if topical is declined.
- If no remission is achieved after 4 weeks, add high dose of aminosalicylates.
- Topical + oral (extensive)

2nd line: Steroids
- Prednisolone, Budesonide (Cortiment), Beclomethsone (Clipper)
- Topical/oral
- Used if aminosalicylate aren’t tolerated.
- Or if no improvement after 4 weeks
- Or 1st line in moderate to severe disease.

3rd line:
- Immunomodulators
- Biologics
- Combination of both

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19
Q

What do you need to consider when safely prescribing aminosalicylate? (13)

A

Ensure correct brand is Rx.

C/I = salicylate allergy

S/e:
- Headache
- Indigestion
- Nausea
- Watery Diarrhoea
- Mild allergic reactions

Rare s/e:
- Blood dyscrasias
- Renal Impairment

Monitoring:
- Renal function = initially @ 3 months and then annually.
- Counselling around blood dyscrasias.

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20
Q

What is the main Rx principle for corticosteroids? (1)

A

Lowest possible dose is initiated = minimises s/e.

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21
Q

What is the correct dosing regimen for prednisolone? (1)

A

30-40mg daily for 1-2 weeks then reduce by 5mg every 5-7 days until stop.

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22
Q

What is the correct dosing regimen for Budesonide (Cortiment)? (2)

A

9mg OD (morning)
Up to 8 weeks

23
Q

What is the correct dosing regimen for Beclometasone (Clipper)? (2)

A

5mg daily (morning)
Up to 4 weeks.

24
Q

When would steroids be used as tx of IBD? (2)

A

Effective at inducing remission.
Unsuitable for maintenance due to s/e.

25
Q

What are the early effects of using steroids? (5)

A

Acne
Oedema
Sleep/Mood disturbances
Dyspepsia
Impaired glucose tolerance

26
Q

What are the delayed effects of corticosteroids? (5)

A

Cataracts
Osteoporosis/Osteonecrosis
Myopathy
Prone to infection
Moon Face

27
Q

What are the glucocorticoid s/e associated with taking steroids? (5)

A

Diabetes
Osteoporosis
Muscle Wasting (Myopathy)
Peptic ulceration + perforation
Psychiatric reactions

28
Q

What are the mineralcorticoid s/e when taking steroids? (5)

A

Hypertension
Sodium Retention
H20 retention
K+ loss
Ca2+ loss

29
Q

What does the adrenal cortex secrete? (2)

A

Hydrocortisone (cortisol) = glucocorticoid activity + weak mineralcorticoid activity.

Mineralcorticoid aldosterone.

30
Q

Explain how adrenal suppression can occur when taking steroids. (1)

A

During prolonged CS tx, adrenal atrophy develops and persists for yrs after stopping.

31
Q

Explain the main effect of acute withdrawal of a steroid (1)

A

Acute withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension/death.

32
Q

What actions should be taken when adrenal suppression occurs? (3)

A

To compensate for a diminished adrenocorticoid response caused by prolonged corticosteroid tx, any significant intercurrent illness, trauma or surgical procedure:

  • Temporary increase in CS dose

OR

  • If already stopped, a temporary reintroduction of CS tx.
33
Q

What action should be taken to reduce the risk of decreased BP during anaesthesia? (1)

A

Anaesthetists must know whether a px is or has been taking a CS.

34
Q

What should be given to patient on long-term CS? (5)

A

Steroid card including the warnings:
- Infections
- Chicken pox
- Measles
- Psychiatric reactions

35
Q

When would consider gradual withdrawal of corticosteroids? (5)

A

> 40mg prednisolone (or equivalent) for > 1 week.

Given repeated doses in the evening.

> 3 weeks tx

Received repeated courses.

Taken short course within 1 year of stopping long-term therapy.

36
Q

What factors can increase the risk of px developing osteoporosis in IBD? (4)

A

High levels of CS
Low BMI
Reduced physical activity
Disease activity

37
Q

How would you manage px with OP with IBD? (4)

A

Manage underlying disease, good nutrition, avoidance of steroids ASAP.

Lowest effective dose / steroids for shortest time possible.

AZA/6MP use at early stage

Biological therapy / surgery considered if px is unable to maintain a steroid free remission.

38
Q

Explain the use of bisphosphonates in OP in IBD. (3)

A

When on steroid for > 65 yrs.

If < 65 but need steroids for > 3 months.

Stopped when steroids stopped unless indicated.

39
Q

Explain the use of calcium + Vit. D in OP and IBD.

A

Not strong evidence is based on BMD but not fractures.

40
Q

What are the tx options for acute severe IBD? (8)

A

1st line:
- IV CCS
- Consider ciclosporin/biologic (infliximab) = if can’t tolerate/decline or c/i = CCS

2nd line:
- Add IV ciclosporin to IV CCS
- No improvement after 72 hrs.
- Worsening symptoms

OR
Biologic (Infliximab)

41
Q

What else do you need to consider when inducing remission for UC? (6)

A

Need for surgery

Supportive Tx = fluids

Stop harmful drugs (NSAIDs, anticholinergics, Opioids)

VTE risk assessment:
- At high risk of VTE
- Rx a LMWH = Tinzaparin

42
Q

Explain how ciclosporin is used in practice. (2)

A

Used to induce/maintain remission.

Brand-Rx

43
Q

What are the common interactions of ciclosporin? (5)

A

Amiodarone
Atorvastatin
Carbamazepine
Clarithromycin
Dabigatran

44
Q

Explain the monitoring process for ciclosporin. (8)

A

Toxicity
Drug ass. mortality = 3%
Check serum cholesterol prior to starting

Monitor:
- BP
- Renal function
- Liver function
- Serum K+, Mg2+
- Drug levels

45
Q

What is the main aim of maintaining remission? (1)

A

To be steroid free.

46
Q

What are the drugs used for maintaining remission? (4)

A

Aminosalicylates
Thiopurines
Biologics +/- Thiopurines

47
Q

Explain the treatment process of maintaining remission in mild-moderate IBD. (4)

A

Proctitis + Proctosigmoiditis:
- Topical +/or oral aminosalicylates (daily/intermittent)

Left-sided + extensive:
- Low-dose oral aminosalicylate.

48
Q

Explain the treatment process for maintaining remission in all extents of disease. (4)

A

Consider oral AZA/6-MP to maintain remission:
- After ≥2 exacerbations in 12 months requiring tx with systemic CCS.

OR

  • If remission isn’t maintained by aminosalicylates.

OR

  • After a single episode of acute severe UC.

Biologics:
- Px with moderate to severe disease.
- Has not responded to conventional therapy, can’t tolerate or it’s c/i.

Janus Kinase Inhibitors (JKI):
- Moderate to severe disease and all other tx options can’t be tolerated or failure.

49
Q

Give an e.g. of a JKI. (1)

A

Tofactinib:
- Non-biologic
- Potent immunosuppressant

50
Q

Explain the key points you need to cover to safely prescribe JKI. (6)

A

Not used with biologics/immunomodulator drugs.

Increased VTE frequency:
- Use with caution in px with add. risk factors for VTE.
- Stop if VTE develops

Not recommended for > 65 yrs.

Monitor lipids 8 weeks after starting tx.

51
Q

What pre-treatment screening is considered for JKI’s? (2)

A

TB
Viral Hepatitis

52
Q

What is a common drug interaction with JKI? (1)

A

CYP3A4 - dose reduced (potent CYP3A4 inhibitors)

53
Q

What the common side effects when taking JKI? (4)

A

Headaches
HPT
Diarrhoea
URTI

54
Q

What is the name of the new drug to help treat UC? Stating its main properties? (5)

A

Etrasimod (Velsipity)
- Mod. to severe active UC
- > 16 yrs
- SIP receptor modulator
- Oral prep
- OD dose

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