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PDAT4 > 29/30 - IBD > Flashcards

29/30 - IBD Flashcards

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1
Q

IBD Risk Factors

Protective Effects

A

HIGH FIBER DIET

  • *HYGIENE**
  • *Larger Family** / # of siblings / living on FARM / PET exposure

Smoking / Apendectomy
only for UC

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2
Q

Which IBD based on Risk Factor?

SMOKING = PROTECTIVE

APENDECTOMY = Protective

A

UC

UC = Smoking / Apendectomy is GOOD

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3
Q

IBD
Risk Factors

A

NSAIDS / ORAL CONTRACEPTIVES

Sedentary Lifestyle

Stress –> gut inflammation

VITAMIN D Deficiency

Allergy to cow milk / high refined sugar intake

Poor Sleep Quality –> inflmamation

Dysbiosis luminal MICROBIOTA

10-25% have Family History

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4
Q

IBD Diagnosis

PHYSICAL EXAM

A

ENDOSCOPY** + **BIOPSY
GOLD STANDARD for Diagnosing IBD

Colonoscopy (5ft) / Sigmoidoscopy (2ft)

EGD = CD only
Esophagogastroduodenoscopy, doesnt include Jejunum/ileum

Wireless Video Capsule
visualize small bowel,gets STUCK, not used often

Imaging Studies = CT Scan / MRE
evaluates the upper GI tract

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5
Q

Ulcerative Colitis Differences

Disease Location

Endoscopic Visualization

Pathalogy

A

Disease Location
confined to JUST THE COLON (okay for EGD)

Endoscopic Visualization

  • *Diffuse Superficial Inflammation / loss of Vascular Structure**
  • *PSEUDOPOLYPS**
  • *Erythema / Friability / Superficial Ulceration**

Pathalogy
Cypt ATROPHY / Neutrophil Infiltration
DIstortion of villous architecture / Paneth Cell metaplasia

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6
Q

Crohn’s Disease Differences

Disease Location

Endoscopic Visualization

Pathalogy

A

Disease Location
ENTIRE GI TRACT, oral cavity -> Rectom
commonl affeccts Terminal Ileum

Endoscopic Visualization

  • *Granulomatous Inflammation = COBBLESTONE**
  • *Skip Lesions** / transmural inflammation

Pathalogy
Crypt abscesses / granulomas
inflammation w/ lymphoid aggregates

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7
Q

Antibody Tests

IBD Serologic Markers​

A

Used to:
DISTINGUISH UC from CD

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8
Q

C-Reactive Protein

IBD Serologic Markers​

A

Non-specific

Can correlate with DISEASE ACTIVITY
&
be used DURING FLARE

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9
Q

Fecal CalProtectin

IBD Serologic Markers​

A

Stool Marker

indentifies LARGE intestinal Inflammation

Correlates with Disease Activity
&
can assist with monitoring Disease PROGRESSION

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10
Q

Naming of UC

A

Proctitis = Rectum
only rectum –> 60-95% of pts

Proctosigmoiditis** = Rectum + Sigmoid Colon

Pancolitis
inflammationt hat extends Past splenic flexure = ALL COLON

Left Sided or Distal Disease
inflammation that extends to splenic Flexure

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11
Q

Which IBD, Clinical Manifestation

AB Pain / Mass

Fatigue / Weight Loss

Fever

Chronic / Nocturnal Diarrhea

A

CROHNS DISEASE

More common in Females, entire GI tract

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12
Q

Which IBD, Clinical Manifestation

Diarrhea +/- Blood

Tenesmus
urge to go when you cant

^Stool Urgency / Frequency

Rectal Bleeding

Toxic Megacolon

A

ULCERATIVE COLITIS

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13
Q

ExtraIntestinal Manifestation = EIM

A

20-40% IBD patients will have inflammation in:
Other Organ Systems

  • *Treating IBD –> treats EIM**
  • may or may NOT correlate with IBD flare*

Rheuma / Derma / Hepata

Ocular / Hemat / Bones

Nephro / Pancrea

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14
Q

Truelove & Witts

Determines Criteria for WHAT & Based on What?

A
  • *UC**
  • *Truelove + Witts**

Mild - Moderate - Severe - Fulminant

Based on:
Stool Frequency / Blood in Stools

Temp / HR / HgB / ESR

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15
Q

CDAI

Determines criteria for WHAT?
&
Severe/Fulminant Criteria

A
  • *CD**
  • *Crohn’s Disease Activity Index**

Severe / Fulminant
CDAI > 450

Persistant Symptoms despite treatment w/ steroids/biologics
OR
High Temp / Vomiting / Obstruction
Peritoneal Signs / Cachexia / Abscess

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16
Q

AminoSalicylates
SulfaSalazine / Balsalazide / Olsalazine
5-ASA = ​Mesalamine

Indicated for what IBD / Severity?

Action / MoA

A

First Line Therapy for:
MILD-MODERATE IBD
to both Induce & Maintain Remission

UC > CD
in terms of effectiveness

Exerts pharmacologic action TOPICALLY in the gut

  • *Anti-Inflammatory**
  • inhibits* proinflammatory prostaglandins / leukotrines / cytokine synthesis
  • *Immunosupressive**
  • BLOCKS* lymphocyte DNA synthesis / T-cell Proliferation
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17
Q

Sulfasalazine
AminoSalicylate

Site of Action / Clinical Pearl

A

Azulfidine @COLON

Male INFERTILITY (reversible)

may turn Urine ORANGE / stain contacts

Needs Folic Acid supplementation

  • *Sulfasalazine = PRODRUG**
  • *Mesalamine (5-ASA) is the ACTIVE drug**
  • *Sulfapyridine causes the SIDE EFFECTS** = HEADACHE
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18
Q

Sulfasalazine
AminoSalicylate

Formulation / Hypersensitivity

A
  • *Sulfasalazine = Prodrug**
    1) Mesalamine = 5-ASA = Active Drug
    2) SULFAPYRIDINE = causes Side effects
  • *DOSE RELATED**, can cause HEADACHE / nausea + fatigue

Hypersensitivity / SULFA ALLERGY
NOT DOSE RELATED
Should be stopped immediately if:
SJS / Fever / Arthralgias / Hepatic or Hematologic Toxicity

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19
Q

Olsalazine
AminoSalicylate

Site of Action / Clinical Pearl

A
  • *Dipentum @ COLON**
  • *2X 5-ASA** joined by AZO bond

Same clinical pearls as Balsalazide

SA: HA / Nausea / Ab pain
WATERY DIARRHEA
15% –> should be switched to –> MESALAMINE agent

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20
Q

Balsalazide
AminoSalicylate

Site of Action / Clinical Pearl

A
  • *Colazal @ COLON**
  • *5-ASA** linked to inert unabsorbed carrier molecule

Same clinical pearls as Olsalazine

SA: HA / Nausea / Ab pain
WATERY DIARRHEA
15% –> should be switched to –> MESALAMINE agent

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21
Q
  • *Mesalamine**
  • *5-ASA (Aminosalycylate)**

ENEMA / RECTUM
site of action

A

Rowasa = Enema
@Descending Colon + Rectum
Give at bedtime + lay on LEFT SIDE for 8 hours

Canasa = Suppository
@ Rectum
need Bowel Movement first

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22
Q

Which Mesalamine Formulation(s) acts on:
TERMINAL ILEUM+Colon

A

“LAD” -> Ileum

Lialda
​1200mg Tab

Asacol HD
800mg Tablet

Delzicol
400mg Cap

ADR of all Mesalamines = Diarrhea @ initiation

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23
Q

Which Mesalamine Formulation(s) acts on:
JEJUNUM + Colon

A

APRISO
375mg Cap

APRISO -> JEJUNUM

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24
Q

Which Mesalamine Formulation(s) acts on:
SMALL BOWEL + Colon

A

PENTASA
250mg / 500mg

  • *PENTA = A LOT
  • -> ENTIRE SMALL + LARGE COLON**
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25
**5-ASA = Mesalamine HyperSensitivity vs Allergy**
_Allergy:_ **Worsening of Colitis Diarrhea / Bleeding / Ab Pain / Fever / HA / Rash** ***D/C and Document as ALLERGY*** **_Hypersensitivity_** should be **D/C'd IF: Pancreatitis / Pneumonitis / Nephrotoxicity**
26
**SULFASALAZINE** **MONITORING**
**Sulfapyridine = Haptotoxicity + Blood Issues** **_CBC_** **_LFTs_** @**initiation of therapy** q2weeks for 3 months q1month for 3 months every 3 months
27
**_5-Asa = Mesalamine_** **MONITORING**
**_SCr_** @6weeks / 6 months / 12 months ## Footnote Use caution in patients with **renal insufficiency**
28
**CorticoSteroids** **IBD INDICATION?** **MoA**
Treatment of: **_ACTIVE UC or CD_** **_MODERATE-SEVERE_** disease who require **RAPID improvement** **_SEVERE-FULMINANT_** disease who **face surgery** ***_FAILED 5-ASA therapy_*** * **_HAS NO ROLE AS MAINTANENCE_*** * ineffective at MAINTAINING remission + side effects* **MoA: Potent Anti-Inflammatory Agent**
29
**Budesonide** Entocort / Uceris ## Footnote **IBD Indication**
Preferred Steroid if: * *_MILD-MODERATE_** symptoms * *LONG-TERM steroids are required** Due to **extensive 1st pass metabolism**: * **_LOW systemic BIOavailability - -\> MINIMIZE SYSTEMIC SIDE EFFECTS_***
30
**_UCERIS_** Budesonide ## Footnote **Formulation / Indication / Target Location**
9mg Oral Tablet + **RECTAL FOAM** * *Active Mild-Moderate _UC_** * _UC-eris_* Targets: **COLON** Rectal formulation: **40cm from Anal Verge**
31
**_Entocort EC_** Budesonide ## Footnote **Formulation / Indication / Target Location**
3mg ORAL capsule **Active _CD_** Maintanence of **Remission CD** Targets: **Terminal Ileum + Ileum + Ascending Colon**
32
**AZA & 6-MP ImmunoModulators for IBD** ## Footnote **Indication / Onset / ADR**
*Not FDA Approved:* Used for **STEROID-SPARING Effect** as **Maintenance Agents** combined **w/ BIOLOGICS --\> *REDUCE IMMUNOGENECITY*** since the Biologic can mount an immune response **3-6 months** ADR: * **_AVOID IN YOUNG MALES_*** due to **Hepatosplenic T-cell Lymphoma** * *_Hepatotoxicity_** (**6-MMP**) * *_Bone Marrow Supression_** (**6-TGN)** * *Infxn / Pancreatitis / GI disturbances / MALIGNANCY**
33
**Which IBD Drug should we avoid in YOUNG MALES?**
**_AZA**_ / _**6-MP_** ImmunoModulator Therapies **BBW** --\> **Hepatosplenic T-Cell Lymphoma** in Young Males
34
**Crohn's Disease COMPLICATIONS**
* **Fistulas**– 40% * **Abscesses** * **Fissures** (**ulcer**) * Nutritional deficiencies – can’t absorb / weight loss * **Obstruction** * **Stricture** – hard to pass * **Intestinal resection** – 60-80%
35
**Which IBD Drug requires TPMT enzyme activity test?**
**_AZA**_ / _**6-MP_** Immunomodulator Therapies **TPMT --\> 6-MMP** = **Hepatotoxic Metabolites** ***_Deficient / Homozygous \<4_*** = *AVOID AZA* ***_Low / HETERozygote 4-12_*** = **Reduce dose by 50%**
36
**Methothrexate What needs to be MONITORED during THERAPY?**
**_CBC**_ + _**LFTs_** weekly 1x month --\> Monthly 3mo --\> q 3 month CBC = **Bone Marrow Suppression** LFT = **Hepatotoxcity** **_PULMONARY FIBROSIS_** = unique ADR Also is **TERATOGENIC**
37
**AZA & 6-MP What needs to be MONITORED during THERAPY?**
**_CBC**_ + _**LFTs_** weekly 1x month --\> Monthly 3mo --\> q 3 month CBC = **Bone Marrow Suppresion from 6-TGN** LFT = **Hepatotoxcity from 6-MMP** **_6-TGN**_ & _**6MMP_** levels if patient is **NOT responding**
38
**CSA + FK (Tacrolimus)** **ImmunoModulators ​**for **IBD** **Indication / Onset / ADR**
*Not FDA Approved for IBD:* used for **SEVERE, Treatment-Refrectory Colitis** (primarily **UC)** **5-14 days** (slow still, but faster) **IV Continuous Infusion** ADR: **_Nephrotoxicity_** / **HT** / **Paresthesia**
39
**Metronidizole / Ciprofloxacin** **Antibiotics ​**for **IBD** **Indication / Onset / ADR**
**_only as ADJUNCTIVE therapy_** used only if they **have an infxn or @risk** Indications: * *CD + Abscess or Fistula** * *Intestinal or Perianal Disease** or **Pouchitis** *concern is C.DIFF* ADR: **Metronidazole = Neuropathy / Metallic Taste / Disulfram Rxn Cipro = Tendon rupture, esp w/ high dose Steroids**
40
**Methotrexate** **ImmunoModulators ​**for **IBD** **Indication / Onset / ADR**
*Not FDA Approved for IBD:* Used for **steroid Sparing effect** as a **Maintenance agent** Combine with **BIOLOGICS** to ***reduce immunogenecity*** **2-8 weeks** (slow) **IM/SC** + **Folic Acid** ADR: **_PULMONARY FIBROSIS_** **Hepatotoxicity / Bone Marrow Suppression** Infection
41
**GOLIMUMAB** ## Footnote **Brand / Class / Indications / Administration**
**Simponi** = Human **Anti-TNFa** **_UC ONLY_** **SC** dosing
42
**CERTOLIZUMAB** ## Footnote **Brand / Class / Indications / Administration**
**Cimzia =** Peg-human **Anti-TNFa** * *_CD ONLY_** * *C**imzia / **C**ertolizumab **SC** dosing
43
**ADALIMUMAB** ## Footnote **Brand / Class / Indications / Administration**
**Humira** = Human **Anti-TNFa** **_CD & UC_** **SC** dosing
44
**INFLIXIMAB** ## Footnote **Brand / Class / Indications / Administration**
**REMICADE** = Chimeric **Anti-TNFa** **CD & UC** Weight Based dosing: **_IV_**
45
**Anti-TNF-a ADRS** Infliximab / Adalimumab / Certolizumab / Golimumab
Can worsen **_CONGESTIVE HEART FAILURE_** = **CHF** **dose related -** avoid 5mg/kg\> of infliximab w/ HF **_Hepatotoxicity_** - LFTs **_Bone Marrow Suppression_** - CBC * *_Infections_** * *TB** / **herpes** / **PCP** / **HEP B** **Injection / Infusion site RXNs** **_BBW_** = **Lymphomas**
46
**Anti-TNFa MONITORING** Infliximab / Adalimumab / Certolizumab / Golimumab
_@Initiation_ * *TB / Hep B** * *CBC / LFT** **Q3 months = CBC / LFT** **Annually = TB / Hep B** **TREAT TB b4 INITIATING THERAPY** 2 months prior to starting
47
**Anti-TNFa THERAPEUTIC DRUG MONITORING = TDM** Infliximab / Adalimumab / Certolizumab / Golimumab
TDM occurs in **LOSS of RESPONSE to therapy** or after a **DRUG HOLIDAY** Monitor **Trough Levels**, immediately prior to next dose **_Drug Levels_** correlate with **longer remission** + **better endoscopy scores** **_Anti-Drug Antibodies = ADA_** ***decrease efficacy** //* increase **infusion / admin rxns** can develop with anti tnf after **prolonged use**
48
**Primary Non-Responder** AntiTNFa for IBD
* *First time Trying --\> NO RESPONSE** * *High TDM Trough level** but **no response** Factors: **long disease duration** \> 2 years **Small bowel extent of disease smoking / normal CRP levels** 60% of patients will respond to another ANTITNFa
49
**Immunomodulator + Anti-TNFa** **Indication for IBD**
* *FIRST LINE THERAPY** for * *_Moderate - Severe CD_** **Consider DUAL therapy based on Patient Factors** for **_Mild-Moderate CD or UC_**
50
**Immunomodulator + Anti-TNFa Combo for IBD** **Positives / Negatives**
Positives: ***_Reduces ANTIBODY formation_*** Increases / maintains - **serum drug concentrations** ***Decrease serum drug clearance*** **= Better Patient Outcomes** _Negative:_ **INCREASED CHANCE FOR LYMPHOMAS + CANCERS**
51
**VEDOLIZUMAB** Brand / Class / Indications / Administration
**Entyvio** **Leukocyte Adhesion Inhbitor** aka Anti-integrin Molecules **_BOTH CD + UC_** First Line (prior to Anti-TNFa) Preffered in patients with **_IMMUNE CONDITIONS_** due to **Gut selectivity --\> *avoids systemic immunosuppression*** **IV dosing**
52
**Which IBD Drug is preferred in patients with: IMMUNE CONDITIONS?** **Organ Transplant / Malignancy**
* *_VEDOLIZUMAB_** = Entyvio * *Leukocyte Adhesion Inhibitor** for **BOTH CD +UC** Due to: * *GUT SELECTIVITY** * avoids systemic immunosuppresion*
53
**NATALIZUMAB** Brand / Class / Indications / Administration
**Tysabri** **Leukocyte Adhesion Inhibitors** **CD - Only** Inadequate / can not tolerate Anti-tnf **IV only**
54
**VEDOLIZUMAB** **MoA / ADRs**
CD & UC _Binds **a4/b7 SELECTIVE for GUT**_ * *Anti-Integrin molecule** - - \> ***reduces leukocyte infiltration & inhibits inflammation*** ADR: * **does NOT need to monitor TB / HEP B*** * *HA / Nasopharyngitis** * lower risk of MALIGNANCY / INFECTIOn*
55
**NATALIZUMAB** **MoA / ADR**
* *CD only** * *Anti-Integrin** --\> acts on **CNS & Gut-Trophic T-cells** **_BBW**_ = _**PML_** Progressive Multifocal Leukoencephalopathy due to ***non-selectivity for GUT*** **_REQUIRES REMS-TOUCH PROGRAM_** ADRs: **Infections / Hepatotoxicity / abnormal WBC**
56
**USTEKINUMAB** Brand / Class / Indications / Administration
**Stelara** **Anti-IL-12 / Anti-IL-23** **ONLY CD Moderate - Severe** for those intolerant of immunomodulators or AntiTNF-a **_Weight Based Loading dose = IV_** + **_Maintance Dose = 90mg SC_**
57
**USTEKINUMAB** **ADR / Monitoring**
* *_DRUG-DRUG INTERCTIONS_** * *CYP substrates** **_TB Test_** @ **Initiation + Yearly** **_CBC_ @Baseline** + **Q3Mo** ADRs: **Reactivation of TB** // **Infections** Malignancy / HA / Fatigue / Inj Site Rxn
58
**TOFACITINIB** Brand / Class / Indications / Administration
**Xeljanz** **JAK Enzyme Inhibitor** prevent gene expression of Cytokines & activity of immune cells for **_UC only_** **Moderate - Severe** * *ORAL DOSING** * no immunogencity = small molecule*
59
**TOFACITINIB MONITORING** **JAK Inhibitor** for **UC only**
**_LIPIDS**_ / _**HERPES ZOSTER INFXN_** **_CBC_** **_Hep B**_ + _**TB Test_** **_CYP3A4 DRUG INTERACTIONS_** avoid inducers | (need Shingrix)
60
**TOFACITINIB ADR's** **JAK Inhibitor for UC only**
Reactivation of: **TB / Hep B / Herpes Zoster** ask about shingrix **Nasopharyngitis / Dyslipidemia** Infection / **HT / Malignancy**
61
**UC Treatment** **Induction / Maintenance**
62
**CD Treatment** **Induction / Maintenance**

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