Week 4.5 - IBD Treatment

Question 1

What are the aims of treatment of IBD?

Answer 1

aim to induce remission and maintain remission

Question 2

What are the step up medications for IBD?

Answer 2

• Aminosalicylates5ASA
• steroids
• immunomodulators
• biologic agents
• surgery

Question 3

When do we use 5ASA’s?

Answer 3

• in UC not CD. induction and maintenance of remission. oral or topical for sigmoid and rectum, + reduce risk of cancer. long term, tolerated well.

Question 4

What is a type of 5ASA we use?

Answer 4

pentasa commonly

Question 5

When do we use steroids?

Answer 5

induce remission for CD and UC.
- prednisolone 40g/day and wean down 4-8 weeks. bad side effects. give Ca2+ and vit D supplement for bones
- budesonide slightly less effective but less side effects

Question 6

What are side effects of long term steroid use?

Answer 6

cataracts, diabetes, obesity, osteoporosis, mood

Question 7

When do we use immunomodulation treatment?

Answer 7

• thiopurines to maintain remission. azathioprine used.
• give to patients who arent settling with 5ASA’s, who have had multiple steroid courses, or another relapse 6-8wks after steroid course1

Question 8

What is methotrexate?

Answer 8

• immunomodulator for CD induce and maintain remission for those steroid dependant.
• teratogenic and bad risks of liver and pulmonary fibrosis, cancers

Question 9

What are risks of immunomodulators?

Answer 9

• affect WBC count
• hepatotoxicity
• pancreatitis
• lymphoma/non-melanoma skin cancer
  DO FREQUENT BLOOD TESTS

Question 10

When do we use biologic agents?

Answer 10

• moderate to severe IBD
• steroids, azathioprine and methotrexate all unsuccessful.

Question 11

What are 3 types of biologic agents?

Answer 11

Anti- TNFa antibodies - inflimab or adalimumab
a4B7 blockers - vedolizumab
IL12/IL23 blockers - ustekinumab

Question 12

What are side effects of biologic agents?

Answer 12

all may cause reactivation of TB in patients with latent disease - check first

Question 13

When do you carry out surgery for UC and ASC? (7)

Answer 13

• acute severe colitis/severe disease
• symptoms not responding to high dose steroids of anti-TNF
• obstructions - perforation or abscess
• frequent relapses despite medical therapy
• unable to tolerate medical therapy
• steroid dependant
• those who chose

Question 13

How often is surgery required in IBD?

Answer 13

• 70-80% of CD require it.
• 30% UC after 10 years.

Question 13

What surgery do we give for acute severe colitis?

Answer 13

subtotal colectomy leaving rectum stoma. may require pouch surgery (elongate small intestine) or removal of rectum
- pouch surgery not recommended for CD as disease may recur

Question 14

What is a limitation of pouch surgery?

Answer 14

• 5 bowel movements a day and 1 overnight even with good pouch
• 20% experience leakage
• usually lasts 10 years

Question 15

What are surgical indications for crohns disease?

Answer 15

• failure of medical management
• relief of obstructive symptoms
• fistula
• manage abscesses
• manage anal conditions
• failure to thrive

Question 16

How long does crohns disease surgery last?

Answer 16

50% need further surgery after 10 years - increased in smokers.