IBD therapy

Question 1

what is the lifestyle advice for IBD?

Answer 1

stop smoking - crohns (esp after surgery)

Diet can influence symptoms but not involved in pathogenesis (low fibre = bowel rest)

Question 2

what effect does smoking have on crohns

Answer 2

clinical, endoscopic and surgical recurrence

Question 3

what drugs are used in crohns?

Answer 3

all have anti-inflammatory effects
depends on severity of flare
Steroids (in severe/acute, not long term)
immunosuppression
Anti-TNF

Question 4

what drugs are used in UC?

Answer 4

5 ASA (mesalazine)
Steroids (in severe/acute, not long term)
Immunosuppressant (step up from 5 ASA)
Anti-TNF

Question 5

how does 5 ASA work?

Answer 5

topical effect
anti-inflammatory effects
acts at mucosal surface
reduces colon cancer risk

Question 6

what are the side effects of 5 ASA?

Answer 6

diarrhoea in some
idiosyncratic nephritis (so need to monitor renal function)

Question 7

how is 5 ASA delivered?

Answer 7

topical
- suppositories
- enemas
oral
- prodrugs
- pH dependant release
- delayed release
Give a combination of topical/oral in acute flare

Question 8

what are some mesalazine derivative agents?

Answer 8

mezavant (delayed release)

Asacol (pH release)

Question 9

what are the limits of topical administered drugs?

Answer 9

suppositories = only reach 20cm of tract but have better adhesion than enemas
enemas = reflex contraction moves liquid/foam enemas proximally

Question 10

when are corticosteroids used?

Answer 10

in acute flares

Question 11

how so corticosteroids work?

Answer 11

anti-inflammatory
induce remission
short course - initially high dose, reduce over 6-8 weeks
Eg. prednisolone or budesomide

Question 12

what are the issues with corticosteroids?

Answer 12

people can become dependant or resistant to the steroids

therefore used as a bridge to maintenance therapy

Question 13

what are the side effects of corticosteroids?

Answer 13

weight gain
diabetes
hypertension
avascular necrosis
osteoporosis
acne
thin skin
neuropsychiatric - can become manic, depressed
cataracts
growth failure (in children)

Question 14

when are immunosupressants used?

Answer 14

after steroids
when more potent inflammatory suppression required
steroid sparing agents in UC
maintenance in crohns

Question 15

which immunosupprssants are used?

Answer 15

azathioprine/merrcaptopurine

methotrexate

Question 16

how do immunosupressants work?

Answer 16

supresses bone marrow
acts on liver
reduces number of WBCs produced

Question 17

how does azathioprine work?

Answer 17

slow onset (16 weeks)
TPMT activity contributes to toxicity
avoid co-prescription of allopurinol (XO inhibitor)
regular blood monitoring required (due to possible effect on bone marrow/liver)

Question 18

what are the side effects of azathioprine?

Answer 18

pancreatitis
leucopaenia
hepatitis
small risk of lymphoma, skin cancer (advice to use high spf sun cream all year round)

Question 19

what are the anti-TNF drugs?

Answer 19

infliximab

adalinumab

Question 20

how does anti-TNF work?

Answer 20

TNF = pro-inflammatory cytokine
drug acts as antibodies to TNF
- infliximab = chimeric
- adalimumab = humanised
promote apoptosis of activated T cells
rapid onset of action

Question 21

how is anti TNF used?

Answer 21

once settled add in th……….

Question 22

how effective is infliximab?

Answer 22

8-12 week remission

good in crohns and UC

Question 23

what are the risks with anti-TNF?

Answer 23

infusion reactions (already have antibodies against the drug)
infection
reactivate latent TB
Cancer (lymphoma, solid tumours)

Question 24

when is anti-TNF used?

Answer 24

as part of long term strategy for immune suppression, surgery (crohns) and supportive therapy
refractory/fistulating disease

Question 25

what are the problems with anti-TNF?

Answer 25

very expensive

biosimilar versions of anti-TNF now available which are cheaper

Question 26

when is surgery implicated?

Answer 26

emergency
- failure to respond to medical therapy
- small bowel obstruction
- abscess
- fistula
elective
- failure to respond to medical therapy
- dysplasia of colon mucosa

Question 27

what is the therapy pyramid for IBD?

Answer 27

smoking cessation
5 ASA (UC)
steroids if needed
immunosuppression
Anti TNF
Surgery