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GI 2 > Pharm - IBD > Flashcards

Pharm - IBD Flashcards

1
Q

clinical and pathological features of UC

the ones bolded by Letassy are starred

A
  • continuous distribution
  • RARELY ileal and transmural involvement
  • crypt abscesses VERY common
  • NO cobblestone appearance
  • uncommon: malaise, fever, abd pain
  • rare: aphthous/linear ulcers, strictures, fistulas
  • rectal involvement is common
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2
Q

clinical and pathological features of CD

the ones bolded by Letassy are starred

A
  • discontinuous distribution
  • ileal involvement VERY common
  • Transmural involvement common
  • crypt abcesses RARE
  • cobblestone appearance common
  • common: malaise, fever, abd pain, strictures, fistulas, aphthous/linear ulcers
  • rectal involvement is rare
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3
Q

proctitis

A

-UC disease confined to the rectum

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4
Q

proctosigmoiditis

A

-UC disease extending to the sigmoid colon only

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5
Q

distal disease (left-sided colitis)

A

-UC disease that only reaches to the splenic flexure

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6
Q

extensive disease (pancolitis)

A

-extends to entire colon

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7
Q

What classifies a UC patient as mild

A
  • <4 stools/day +/- blood
  • no systemic complications
  • normal ESR (0-30 mm/h)
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8
Q

What classifies a UC patient as moderate

A
  • > 4 stools/day with blood

- minimal systemic complications

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9
Q

What classifies a UC patient as severe

A
  • > or equal to 6 stools/day with blood and cramps
  • evidence of systemic complications as indicated by:
  • fever (>37.5 C)
  • tachy (>90 BPM)
  • anemia (<10.5 g/dl)
  • ESR > 30 mm/hr
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10
Q

What classifies a UC patient as fulminant

A
  • > 10 stools/day with continuous bleeding, toxicity, abd pain and tenderness, distension, fever, anorexia, may require transfusions
  • pts are at risk of progressing to toxic megacolon and bowel perf
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11
Q

Crohn’s disease classification: asymptomatic remission

-note: CDAI = Crohn’s disease activity index)

A
  • CDAI <150
  • pts who are asymptomatic either spontaneously or after a medical/surgical intervention
  • pts requiring steroid to remain asymptomatic are NOT considered to be in remission but are referred to as “steroid-dependent”
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12
Q

Crohn’s disease classification: mild/moderate

A
  • CDAI: 150-219
  • ambulatory pts able to tolerate diet w/o manifestation of dehydration, systemic toxicity, abd tenderness, painful mass, intestinal obstruction or >10% weight loss
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13
Q

Crohn’s disease classification: moderate/severe

A
  • CDAI: 220-450
  • pts that fail to respond to tx for mild/moderate dz or have more prominent sx of: fever, weight los, abd pain/tenderness, intermittent N/V (w/o obstruction) or anemia
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14
Q

Crohn’s disease classification: severe/fulminant

A
  • CDAI: >450
  • presence of persistent sx despite outpatient corticosteroid or biologic tx OR evidence of systemic toxicity: high fevers, persistent vomiting, intestinal obstruction, significant peritoneal signs, presence of cachexia or abcess
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15
Q

what are the goals of tx for CD and UC?

A
  • resolve the acute/active inflammatory process (induce clinical remission)
  • resolution of local and systemic complications
  • maintain remission
  • surgical palliation or cure
  • improve quality of life
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16
Q

In which disease is surgery NOT curative?

A
  • CD

- however may be used to manage dz

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17
Q

In which disease IS surgery curative?

A
  • UC

- indicated when dz is uncontrolled on optimized medical therapy or for management of complications

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18
Q

class: 5-ASA (aminosalicylic acid) derivative

- list the drugs (4)

A
  • sulfasalazine
  • mesalamine
  • olsalazine
  • balsalazide
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19
Q

class: corticosteroids

- list drugs (6)

A
  • hydrocortisone
  • prednisone
  • budesonide (CIR)
  • budesonide-MMX
  • hydrocortisone IV
  • methylprednisolone IV
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20
Q

class: immunosuppressants

- list drugs (4)

A
  • azathioprine
  • 6-mercaptopurine
  • cyclosporine
  • methotrexate
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21
Q

class: biologics (TNF-alpha inhibitors)

- list drugs (3)

A
  • infliximab (remicade)
  • adalimumab (humera)
  • certolizumab (cimzia)
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22
Q

class: anti-integrin abs

- list drugs (2)

A
  • natalizumab (tysabri)

- vedolizumab (entyvio)

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23
Q

what is the preferred 5-ASA derivative?

A

mesalamine (better tolerated than sulfasalzine)

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24
Q

oral vs topical mesalamine

A
  • oral: used for extensive disease

- topical: used for distal disease or proctitis

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25
Q

mesalamine drug interactions

A

avoid:
- antiacids
- H2RAs (ranitidine/famotidine)
- PPIs

-safe to use in pts w/ sulfa allergy

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26
Q

sulfasalazine MoA

A
  • combo of sulfapyridine and mesalamine
  • it is cleaved into those 2 products, mesalamine being the active one
  • but true MoA is not well understood
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27
Q

sulfasalazine vs mesalamine

A

-sulfasalazine is commonly used vs oral mesalamine b/c of low cost BUT it’s not well tolerated

28
Q

sulfasalazine contraindications

A

-sulfa allergy

29
Q

counseling points for sulfasalazine

A
  • it impairs folic acid absorption

- take a supplement (1 mg/day)

30
Q

What is the sulfasalazine product brand name?

A

Azulfidine

31
Q

mesalamine ORAL products

  • list 2
  • what formulation
A
  • pentasa: controlled-release capsule

- lialda: delayed and extended release tab, multimatrix (UC and CD)

32
Q

mesalamine TOPICAL products

  • list 2
  • what formulation
A
  • canasa: 1 g suppository

- rowasa: 2g-4g retention enema

33
Q

Canasa counseling points

A
  • reserved for proctitis
  • BID to induce remission
  • administered at bedtime to maintain remission
34
Q

Rowasa counseling points

A

-enemas reach to the splenic flexure and can be used for distal disease AND proctitis

35
Q

balsaladize products

  • list 2
  • formulation
A
  • colazal: capsule

- giazo: tab

36
Q

given the dosage form, indicate what part of the colon it will reach

A
  • enema: will reach proximal sigmoid colon and splenic flexure
  • foam prep: will reach mid-sigmoid colon (1/2 way)
  • suppositories: distal 5-8 cm of rectum
37
Q

oral agents coverage of colon

A
  • review chart on pg 11
  • Pentasa covers almost everything
  • lialda covers all of the colon
38
Q

MoA of corticosteroids

A

modulate the immune system and inhibit production of cytokines and inflammatory mediators

39
Q

general comments on corticosteroids

A
  • use for ACUTE management only - not desirable for maintenance/chronic use
  • rectal formulations: used in distal dz
  • oral: used in more extensive dz not responding to oral 5-ASA
  • IV: reserved for those w/ s/s of systemic complications and severe dz not responding to other therapies
40
Q

ADRs of corticosteroids

A
  • HPA axis suppression
  • increase risk of infection
  • immunosuppression
  • increase in glucose
  • increase WBC
  • increase BP
  • weight gain
  • edema
  • alteration in mood/insomnia
  • osteoporosis (long term)
41
Q

what is an important counseling point for corticosteroid?

A

do not stop abruptly

42
Q

hydrocortisone

  • list products (2)
  • formulations
  • what type of dz they tx
A
  • cortenema: enema; reserved for proctitis or distal dz

- cortifoam: foam enema; reserved for proctitis or distal dz

43
Q

budesonide CIR

  • list product
  • formulation
  • what dz tx
A
  • entocort: PO - controlled release into the ileum (think CD)
  • first-line for CD confined to the ileum and/or right colon
44
Q

budesonide-MMX

  • list product
  • formulation
  • what dz tx
A
  • uceris: PO delayed release and extended release tab, multimatrix, controlled release into colon
  • extends the release of the drug into the colon for use in mild/moderate UC
45
Q

What type of pt are immunosuppressants used in?

A
  • those who are steroid dependent
  • refractory to steroids or
  • for attaining remission in those w/ inadequate response to 5-ASA derivatives
46
Q

general comments on immunosuppressants

A
  • used in conjunction w/ mesalamine derivative and/or steroids
  • must be used long-term (months) before benefits are seen, so NOT acute relief
  • may be steroid-sparing
  • counsel pts that it may take months to see benefits
47
Q

ADRs of azathioprine

A
  • hepatosplenic T-cell lymphoma
  • neutropenia
  • hepatotoxicity
  • nephrotoxicity
  • myelosuppression
48
Q

6-mercaptopurine ADRs

A
  • hepatosplenic T-cell lymphoma
  • neutropenia
  • hepatotoxicity
  • nephrotoxicity
  • myelosuppression
49
Q

cyclosporine ADRs

A
  • hyperglycemia
  • nephrotoxicity
  • HTN
  • neurological toxicity
50
Q

methotrexate ADRs

A
  • myelosupression
  • hapatotoxicity
  • pulmonary toxicity
51
Q

when to use methotrexate

A

-after mercaptopurine or cyclosporine

52
Q

What are the antibiotics used to tx UC and CD? (2)

A
  • metronidazole

- cipro

53
Q

important fact before starting a TNF-alpha inhibitor

A
  • must r/o TB before using them

- they can reactivate latent disease

54
Q

notes on infliximab (remicade)

A
  • development of abs to infliximab
  • can lead to serious infusion reactions or loss of response to drug
  • reduce formation of these by giving a 2nd dose w/i 8 weeks of initial dose, concurrent admin of steroids and use of concomitant immunosuppressive agents
55
Q

general comments on anti-integrin antibodies

A
  • used in tx of CD for pts who are unresponsive to other therapies
  • should NOT be used in combo w/ immunosuppressants or TNF-alpha inhibitors
  • ADR: PML (progressive multifocal leukoencephalopathy)
56
Q

In a pt w/ mild to moderate UC who is experiencing a flare, what is the best medication and dosage form?

A
  • topical 5-ASA (mesalamine)
  • induce remission in >90% of pts
  • proctitis: supp
  • proctosigmoiditis: enema
57
Q

maintenance therapy in a FIRST epidsode of mild proctitis

A

NOT recommended

58
Q

when is maintenance therapy recommended in UC?

A
  • in pts w/ UC who have more than 1 relapse a yr

- in ALL pts w/ proctosigmoiditis

59
Q

given a pt w/ mild/moderate UC that is more extensive, what is the appropriate combo of meds to induce and maintain remission?
-note: this includes left sided colitis (distal dz), extensive colitis, and pancolitis

A
  1. oral 5-ASA
    - all mesalamine products are equally effective
    - balsalazide may be slightly better
  2. 5-ASA or steroid suppository
  3. steroid enemas or foam
60
Q

What is the advantage of budesonide MMX over oral prednisone?

A

it is designed to release budesonide in the colon

61
Q

note on severe/fulminant UC tx

A
  • Letassy doesn’t have a LO for this
  • but there are things highlighted from her packet
  • maybe review pg 17 for this?
62
Q

What prophylactic tx is needed for pts hospitalized w/ UC and CD

A

heparin to prevent DVTs

63
Q

given a pts w/ mild/moderate Crohn’s dz, what is the appropriate first line tx to induce remission?

A
  • of the ileum and proximal colon:

- enteric coated budesonide (entocort)

64
Q

given a pts w/ mild/moderate Crohn’s dz, what is the appropriate alternative tx to induce remission in a pt who cannot tolerate first line tx?

A

prednisone

65
Q

What is the advantage of budesonide CIR over oral prednisode in CD?

A

less systemic effects

66
Q

adjunct therapies in crohn’s dz

A
  • antidiarrheals: loperamide
  • BAS if chronic watery diarrhea
  • probiotics: NO evidence
  • lactose avoidance: can help decrease sx
  • eliminate other food triggers

GI 2 (11 decks)

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