66. Inflammatory Bowel Disease (IBD) Flashcards Preview

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Flashcards in 66. Inflammatory Bowel Disease (IBD) Deck (33):
1

A physician has ordered infliximab. The pharmacist calls the prescriber to ask if she wishes to pre-medicate with acetaminophen, antihistamine and steroids. Which of the following statements is correct?

A. This regimen may be used for infusion related reactions from infliximab therapy.
B. This regimen may be used for infusion related reactions from fluconazole therapy.
C. This regimen may be used for infusion related reactions from tacrolimus therapy.
D. This regimen is missing ondansetron for prophylaxis against nausea and vomiting.
E. Only acetaminophen and an antihistamine should be used for infusion related reactions from infliximab. Steroids should be avoided due to side effect profile.

A. Patients on infliximab may be pre-treated with acetaminophen, antihistamine and/or steroids to prevent infusion reactions, such as hypotension, fever, chills, and pruritus.

2

Chief Complaint:  “I am going to the bathroom 10 times a day"
History of Present Illness: MJ is a 32 y/o female who presents to the ER today.  She describes a 2-week history of increasing abdominal pain and frequency of bowel movements.  It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day.  There is now blood in the stool sometimes.  She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse.  She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much.  MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).    
Allergies:  sulfa

Past Medical History:  none
Medications:  Seasonique   
                
Physical Exam / Vitals: 
Height: 5’10”  Weight: 122 pounds    
BP: 128/75 mmHg  HR: 102 BPM  RR: 14 BPM Temp: 99.2°F  Pain: 2/10

Labs:
Na (mEq/L) = 142 (135 – 145)              

WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)       
K (mEq/L) = 4.8 (3.5 – 5)                      

Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)              

Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)              

ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)      

Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)            

ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)   
Mg (mEq/L) = 1.9 (1.3 – 2.1)                 
PO4 (mg/dL) = 4.2 (2.3 – 4.7)                
                                                               
Tests: 
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum.  Rectum appears unaffected.  Numerous strictures and bleeding are noted throughout GI tract.   
Plan: 
Admit for consultation with GI service.
Question: 
MJ needs to be treated for her acute IBD exacerbation.  Which of the following is an appropriate recommendation?

A. Vedolizumab IV
B. Certolizumab SC
C. Loperamide PO
D. Prednisone PO
E. Methotrexate PO

D. Exacerbations of UC and Crohn's are treated with short courses of IV or oral steroids.

3

Which of the following can occur with the use of infliximab? (Select ALL that apply.)

A. Infusion-related reactions
B. Renal insufficiency
C. Antibody induction
D. Hepatotoxicity
E. Reactivation of latent TB

A, C, D, E. Use of infliximab can be associated with infusion-related reactions (hypotension, fever, chills, pruritus), antibody induction, hepatotoxicity, and reactivation of latent TB.

4

Chief Complaint:  “I am going to the bathroom 10 times a day"
History of Present Illness: MJ is a 32 y/o female who presents to the ER today.  She describes a 2-week history of increasing abdominal pain and frequency of bowel movements.  It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day.  There is now blood in the stool sometimes.  She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse.  She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much.  MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).    
Allergies:  sulfa

Past Medical History:  none
Medications:  Seasonique   
                
Physical Exam / Vitals: 
Height: 5’10”  Weight: 122 pounds    
BP: 128/75 mmHg  HR: 102 BPM  RR: 14 BPM Temp: 99.2°F  Pain: 5/10

Labs:
Na (mEq/L) = 142 (135 – 145)              

WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)       
K (mEq/L) = 4.8 (3.5 – 5)                      

Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)              

Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)              

ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)      

Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)            

ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)   
Mg (mEq/L) = 1.9 (1.3 – 2.1)                 
PO4 (mg/dL) = 4.2 (2.3 – 4.7)                
                                                               
Tests: 
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum.  Rectum appears unaffected.  Numerous strictures and bleeding are noted throughout GI tract.   
Plan: 
Admit for consultation with GI service.
Question: 
The Gastroenterologist diagnoses MJ with Crohn's disease.  After 72 hours of therapy in the hospital she is feeling better, having fewer loose stools, and less pain.  Which of the following is the best medication to discharge MJ on?

A. Entocort EC capsules PO
B. Uceris tablets PO
C. Uceris rectal foam
D. Azulfadine PO
E. Canasa suppositories

A. MJ has Crohn's disease of the ascending/transverse colon and ileum. Entocort EC is specifically indicated for Crohn's in that location. She does not have distal disease, so topical products will not be effective. Uceris tablets are indicated only for UC. The patient has a sulfa allergy.

5

Which of the following drugs can cause the skin or urine to become orange-yellowish in color?

A. Methotrexate
B. Mesalamine
C. Ciprofloxacin
D. Infliximab
E. Sulfasalazine

E. Sulfasalazine can cause the skin or urine to become orange-yellowish in color. It is considered harmless but can stain clothing.

6

A patient with ulcerative colitis is being initated on sulfasalazine therapy. Which of the following situations would represent a contraindication to the use of sulfasalazine?

A. A history of coronary artery disease
B. High triglycerides
C. A history of gout
D. A history of severe sunburns
E. A sulfa or salicylate allergy

E. Sulfasalazine is contraindicated in patients with a sulfa or salicylate allergy. Remember it is an aminosalicylate. Mesalamine can be used in patients with a sulfa allergy.

7

In addition to loperamide, which other agent is sometimes used to help control diarrhea in patients with Crohn’s?

A. Psyllium
B. Sennosides
C. Docusate
D. Bisacodyl
E. Mineral oil

A. Psyllium and other bulk-forming agents may be useful to treat diarrhea in patients with Crohn's disease. Psyllium is useful for both diarrhea (by firming up stool) and for constipation (by mixing in and making the stool more spongy).

8

Which of the following is a first-line treatment option for a patient newly diagnosed with distal mild-to-moderate ulcerative colitis?

A. Sulfasalazine oral
B. Azathioprine oral
C. Mesalamine suppository
D. Infliximab injection
E. Methotrexate oral

C. Mesalamine enemas or mesalamine rectal suppositories are first-line for mild-to-moderate distal ulcerative colitis. When treating distal disease (rectum and colon) it is preferable to insert the medication into the rectum to apply the treatment where the problem is, rather than using systemic therapy, which is not as targeted and will cause more side effects.

9

Which of the following are true statements regarding mesalamine enemas? (Select ALL that apply.)

A. Administer once daily at bedtime.
B. Patients should ideally retain overnight (8 hours).
C. Topical mesalamine is preferred for proximal disease.
D. The medication is generally prescribed for 1 week at a time because it is poorly tolerated.
E. Store at room temperature.

A, B, E. Mesalamine enemas should be administered once daily at bedtime and ideally, retained for 8 hours. They can be stored at room temperature. Topical mesalamine is the route of choice for distal disease (primarily in ulcerative colitis).

10

A patient has received oral prednisone 40 mg x 7 days for an acute flare of ulcerative colitis. Which of the following short-term adverse effects may occur?

A. Cataracts and poor wound healing
B. Osteoporosis and immunosuppression
C. Fat deposits in the face and adrenal suppression
D. Cushing syndrome and growth retardation
E. Insomnia and mood changes

E. A patient started on 40 mg daily of prednisone may experience elevated blood pressure, changes in mood, and elevated glood glucose, among other adverse effects. The remaining choices are long-term adverse effects of corticosteroids.

11

Chief Complaint:  “I am going to the bathroom 10 times a day"
History of Present Illness: MJ is a 32 y/o female who presents to the ER today.  She describes a 2-week history of increasing abdominal pain and frequency of bowel movements.  It started with 4-5 bowel movements per day and escalated to 6-8 bowel movements per day.  There is now blood in the stool sometimes.  She is only eating Gatorade and saltine crackers for fear that the diarrhea and pain will get worse.  She has lost weight, but doesn't weigh herself regularly, so she doesn't know how much.  MJ has not traveled out of the country and has eaten the same foods as her husband (and he is not ill).    
Allergies:  sulfa

Past Medical History:  none
Medications:  Seasonique   
                
Physical Exam / Vitals: 
Height: 5’10”  Weight: 122 pounds    
BP: 128/75 mmHg  HR: 102 BPM  RR: 14 BPM Temp: 99.2°F  Pain: 2/10

Labs:
Na (mEq/L) = 142 (135 – 145)              

WBC (cells/mm3) = 9.3 (4 – 11 x 10^3)       
K (mEq/L) = 4.8 (3.5 – 5)                      

Hgb (g/dL) = 12.9 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 39.2 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 26 (24 – 30)              

Plt (cells/mm3) = 399 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 15 (10 – 40)
SCr (mg/dL) = 1.0 (0.6 – 1.3)              

ALT (IU/L) = 12 (10 – 40)
Glucose (mg/dL) = 79 (100 – 125)      

Albumin (g/dL) = 4.5 (3.5 – 5)
Ca (mg/dL) = 10.1 (8.5 – 10.5)            

ESR (mm/hr) = 12 (≤ 20 male, ≤ 30 female)   
Mg (mEq/L) = 1.9 (1.3 – 2.1)                 
PO4 (mg/dL) = 4.2 (2.3 – 4.7)                
                                                               
Tests: 
CT of the abdomen: Discontinuous pattern of inflammation in the ascending/transverse colon and ileum.  Rectum appears unaffected.  Numerous strictures and bleeding are noted throughout GI tract.   
Plan: 
Admit for consultation with GI service.
Question: 
Based on the case above, what is MJ's most likely diagnosis?

A. Irritable bowel syndrome
B. Ulcerative colitis
C. Crohn’s disease
D. Infectious diarrhea
E. C. difficile associated diarrhea

C. MJ most likely has Crohn's disease based on the presence of numerous strictures, discontinuous pattern of inflammation, and location throughout the GI tract. Her colon and ileum are affected and rectum is spared. UC generally affects the rectum.

12

Which statements are true regarding Asacol HD? (Select ALL that apply.)

A. It contains salicylates.
B. It is delayed-release.
C. It should be avoided in a patient who has difficulty breathing with aspirin.
D. It can be crushed and administered via a nasogastric tube
E. The patient may see Asacol HD in the stool.

A, B, C, E. Asacol HD is a delayed-release oral mesalamine tablet administered TID. It contains salicylates and should be avoided in patients with a salicylate allergy. The patient may see a ghost tablet in the feces, they should not be alarmed.

13

Which of the following are monoclonal antibodies approved for the treatment of IBD?

A. Remicade, Rituxan, Cimzia
B. Humira, Remicade, Tysabri
C. Rituxan, Entyvio, Simponi
D. Humira, Enbrel, Cimzia
E. Remicade, Simponi, Enbrel

B. Rituxan and Enbrel are not approved for IBD. The monoclonal antibodies that are approved for IBD have specific FDA-approved indications for UC, CD, or both.

14

Which of the following is true of vedolizumab?

A. Vedolizumab is approved only for Crohn's disease.
B. Vedolizumab has a boxed warning for PML.
C. The brand name of vedolizumab is Entyvio
D. Vedolizumab must be used in conjunction with another immunosuppressant.
E. Vedolizumab is an integrin receptor agonist.

C. Vedolizumab was approved in 2014 for UC and Crohn's disease. It is a monoclonal antibody - specifically an integrin receptor antagonist. Patients on vedolizumab should be monitored for PML, though it has not been observed with this drug to date.

15

Keith has ulcerative colitis that is extensive. He has been started on sulfasalazine therapy. Choose the correct counseling statement for sulfasalazine:

A. The brand name is Asacol-HD.
B. Common side effects are headache, nausea and decreased appetite.
C. Sulfasalazine is contraindicated in a penicillin allergy.
D. Take this medication before meals on an empty stomach.
E. Sulfasalazine is also used to treat osteoarthritis.

B. Counseling points for sulfasalazine delayed-release tablets (Azulfidine EN-tabs) include: can rarely cause serious blood disorders, including agranulocytosis. Patients should be instructed to report at once if they have symptoms of an infection (fever, sore throat). It is contraindicated in a sulfa allergy. Drink plenty of fluids during treatment with this medication to help prevent kidney stones. Take after a meal when there is food in the stomach.

16

Sulfasalazine can reduce absorption of which medication?

A. Metoclopramide
B. Metoprolol
C. Spironolactone
D. Folic acid
E. Methotrexate

D. Sulfasalazine can reduce the absorption of folate. Patients can take 1 mg/day of folic acid to supplement.

17

Which of the following is true regarding natalizumab?

A. The brand name is Cimzia.
B. It is given SC.
C. There is a boxed warning for PML.
D. It is a first-line option for Crohn's.
E. It is approved for both UC and Crohn's.

C. Natalizumab has a boxed warning for progressive multifocal leukoencephalopathy (PML).

18

Which steroids are available as rectal foam products for IBD?

A. Prednisone and budesonide
B. Budesonide and dexamethasone
C. Hydrocortisone and prednisone
D. Hydrocortisone and methylprednisolone
E. Budesonide and hydrocortisone

E. Budesonide and hydrocortisone are available as rectal foam products.

19

What is meant by the term "distal" ulcerative colitis

A. Near the duodenum
B. Near the rectum
C. Near the ileum
D. Near the lower esophageal sphincter
E. Adjacent to the stomach

B. Distal ulcerative colitis refers to disease occurring near the rectum (and the most distal part of the colon, called the sigmoid colon). Topical agents (mesalamine enema, suppository) should be used first-line in distal disease.

20

A physician has written a prescription for Entocort EC. Choose the appropriate therapeutic interchange:

A. Prednisone
B. Budesonide
C. Azathioprine
D. Mesalamine suppository
E. Sulfasalazine

B. Budesonide is the appropriate therapeutic interchange for Entocort EC.

21

Which of the following are true statements regarding aminosalicylates? (Select ALL that apply.)

A. Giazo is only approved for males.
B. The toxicities of each agent are similar.
C. Sulfasalazine is the preferred aminosalicylate.
D. Mesalamine should be not be administered with PPIs, H2RAs, or antacids.
E. Salicylate allergy is a contraindication.

A, D, E. Giazo is only approved for males. Sulfasalazine has significantly more toxicities than the other agents and is not the preferred agent. Mesalamine should be separated from acid-suppression therapy. All aminosalicylates are contraindicated in patients with a salicylate allergy.

22

Patients with ulcerative colitis or Crohn's may be using loperamide for occasional diarrhea, or dicyclomine as an antispasmodic (to control cramps). Choose the correct statement concerning dicyclomine:

A. The brand name is Entocort.
B. Dicyclomine is a cholinergic medication.
C. Dicyclomine can cause dry mouth.
D. Dicyclomine can cause urinary frequency.
E. Dicyclomine causes excessive tearing in many patients.

C. The most common antispasmodic is dicyclomine, given 10 mg AC and QHS. This is an anticholinergic; dizziness and dry mouth are the most common side effects.

23

What is the brand name of azathioprine?

A. Zyloprim
B. Imuran
C. Azulfidine
D. Asacol
E. Rowasa

B. The brand name of azathioprine is Imuran.

24

Which of the following medications is considered a first line option for a patient newly diagnosed with mild to moderate Crohn’s disease?

A. 6-mercaptopurine
B. Metronidazole
C. Ciprofloxacin
D. Infliximab
E. Oral budesonide

E. Oral budesonide or topical steroids are preferred for mild-moderate CD. The topical steroids are not effective for maintaining remission. An oral aminosalicylate (sulfasalazine or mesalamine) may provide adequate symptom control for many patients with mild to moderate Crohn's, but also will not maintain remission.

25

A physician has written a prescription for Pentasa. Pentasa contains the following drug:

A. Prednisone
B. Budesonide
C. Azathioprine
D. Mesalamine
E. Sulfasalazine

D. Pentasa is a controlled-release oral formulation of mesalamine.

26

Which of the following is a brand name for mesalamine? (Select ALL that apply.)

A. Lialda
B. Pentasa
C. Rowasa
D. Asacol HD
E. Canasa

A, B, C, D, E. Canasa, Lialda, Pentasa, Rowasa, and Asacol HD are all brand names for mesalamine.

27

The following can trigger symptoms in patients with inflammatory bowel disease: (Select ALL that apply.)

A. NSAIDs
B. Meats
C. Infection
D. Lactose-free dairy products
E. Beans, cabbage, broccoli

A, C, E. Food triggers in IBD are highly patient-specific. Fatty foods and gas-producing foods are often triggers.

28

Which of the following describes the mechanism of action of infliximab?

A. Chimeric monoclonal antibody against integrin
B. Chimeric monoclonal antibody against interleukin-1
C. Chimeric monoclonal antibody against TNF
D. Fully humanized monoclonal antibody against integrin
E. Fully humanized monoclonal antibody against TNF

C. Chimeric antibody antagonists, such as infliximab, are not fully humanized. This results in antibody production in a large percentage of patients (up to 50%). This causes the drug to become less effective.

29

A patient has a prescription for mesalamine rectal suppositories for ulcerative colitis symptoms. Which of the following statements is correct?

A. Mesalamine comes in an oral formulation only.
B. The suppository should be rolled into a point prior to insertion.
C. The suppository should be kept in the rectum for 1-3 hours, or preferably overnight.
D. Mesalamine is indicated for patients who have failed to achieve symptom control with infliximab.
E. Mesalamine suppositories are not recommended for distal symptoms.

C. Mesalamine is available in long-acting oral formulations, rectal suppositories and enemas. Distal disease can often be treated locally (via drug delivery by suppositories or enemas). Suppositories melt quickly and should be handled as little as possible. In general, drugs given rectally or vaginally are given prior to bed. When the patient is lying down, the medication will be retained in the body for a longer period of time.

30

A patient with severe Crohn's disease will receive infliximab therapy. Which of the following statements is correct? (SelectALL that apply.)

A. The brand name is Entyvio.
B. Infusion-related reactions from infliximab are common (hypotension, fever, chills, pruritus).
C. Patients should be screened for TB before starting this agent.
D. Infliximab is administered by subcutaneous injection; no oral formulation is available.
E. This is the agent of choice in patients with concomitant heart failure.

B, C. Infliximab (Remicade) is a monoclonal antibody to TNF. Patients must be evaluated for TB prior to starting this agent. Infliximab is administered via IV infusion - pretreatment with diphenhydramine, acetaminophen, and/or steroids is recommended can help with infusions reactions. Use with caution in patients with moderate-severe heart failure.

31

Choose the correct statement concerning budesonide in the treatment of IBD:

A. It is poorly tolerated and is usually reserved for patients who do not respond well to prednisone.
B. Budesonide has no drug interactions.
C. The capsule can be opened and sprinkled in a small amount of applesauce or pudding.
D. Budesonide is generally used for eight weeks at a time to treat active disease (for treatment of an acute flare).
E. Budesonide works better than prednisone in treating the disease symptoms.

D. Budesonide (Entocort EC, Uceris) is a nonsystemic oral steroid; 90% of the drug stays in the gut. There are fewer severe side effects than with an equivalent treatment dose of prednisone. Do not open, chew or crush the capsules. Budesonide does not work as well as prednisone, but because it has less severe side effects, it is commonly used first. Budesonide is a major CYP 3A4 substrate.

32

The term Inflammatory Bowel Disease (IBD) refers primarily to the following condition/s (Select ALL that apply.)

A. Crohn's disease
B. Ulcerative colitis
C. Inflammation of the gut lining caused by chronic infection, such as from H. pylori disease
D. Irritable bowel syndrome
E. Stomatitis

A, B. Two major types of IBD are ulcerative colitis (UC) and Crohn's disease. Ulcerative colitis is limited to the colon (large intestine). Although Crohn's disease can involve any part of the gastrointestinal tract from the mouth to the anus, it most commonly affects the small intestine and/or the colon.

33

Which of the following is not an important counseling point for a patient starting Cortifoam?

A. After use, take apart and clean the parts with warm water for next use.
B. Throw away the applicator and dispense the foam directly from the foam container into the anus.
C. Wait 5-10 seconds for the foam to expand and fill the applicator barrel.
D. Hold the applicator firmly, insert the tip into the anus, and push the plunger to expel the foam.
E. Shake the foam container well for 5-10 seconds before using.

B. The foam container should never be inserted into the anus, only the applicator should be used.

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