- Confined to rectum + colon - Continuous inflammation - Progressive disease - NO perianal involvement

- Toxic megacolon - Colon cancer

- Rowasa: enema, delivers to the rectum and distal colon - Canasa: suppository, delivers to rectum ONLY - Pentasa: oral, delivers 5-ASA from rectum to jejunum (largest range of any rx)

IBD Flashcards by Chelsey Case

IBD S/Sx

*Blood in stool
Diarrhea
Abdominal pain/cramps
Weight loss
Fatigue
Change in QoL

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IBD Diagnosis

*Monitor Labs (ESR, CRP)
*Stool Studies (Lactoferrin, Calprotectin, Leukocytes)
Monitor symptoms
Colonoscopy
CT/MRIs

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Types of UC

a. Proctitis: Only rectum

b. Left sided/Distal Colitis: involvement up to splenic flexure

c. Extensive/Pancolitis: involves entire large intestine

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UC characteristics

Confined to rectum + colon
Continuous inflammation
Progressive disease
NO perianal involvement

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UC complications

Toxic megacolon
Colon cancer

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Chron’s characteristics

Mouth to anus (entire GI tract)
Most common in terminal ileum
deep, patchy crypts
“cobblestone appearance”
Inc perianal involvement

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Chron’s complications

Malnutrition/vitamin deficiency (SI involved)
Strictures
Fistulas/fissures (perianal involvement)

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5-aminosalicylates - Drugs

Sulfasalazine
*Mesalamine
Olsalazine
Basalazide

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Mesalamine preps

Rowasa: enema, delivers to the rectum and distal colon
Canasa: suppository, delivers to rectum ONLY
Pentasa: oral, delivers 5-ASA from rectum to jejunum (largest range of any rx)

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Which disease are 5-ASA preferred?

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Immunomodulators - Drugs

*Azathioprine
6 - Mercaptopurine
Methotrexate
Cyclosporine

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Benefits of combining Azathioprine with steroids/biologics?

a. Delayed effect (~3 months)

b. Steroid sparing (avoids long-term steroid therapy)

c. Inc efficacy of biologics due to dec antibody formation

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Monitoring parameters on Azathioprine

a. CBC every 3 months

b. LFT/pancreatic enzymes

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Azathioprine BBW

Lymphoma (inc. risk when combo with biologics)

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Antibiotics - Drugs

Metronidazole
Ciprofloxacin
3rd gen cephalosporins

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Which disease are ABX more commonly used?

Chron’s: perianal involvement (fistula/fissures)
- used short term to aid in closure
- cover gram(-) / anaerobes

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Corticosteroids - Drugs

Prednisone
Methylprednisolone
Hydrocortisone
Budesonide

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Budesonide formulations

a. Entocort: Chron’s (reaches terminal ileum)

b. Uceris: UC (only colon)

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Benefits of Budesonide in IBD

15x potency vs Prednisone
Poor systemic absorption = decreased ADEs
do NOT combo with other steroids
8 week course of therapy

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Biologics - Types

Anti-TNFs
Selective adhesion molecule (integrin) inhibitor
IL inhibitors

Anti-TNF - Drugs

Infliximab (IV)
Adalimumab (SQ)
Certolizumab (SQ)
Golimumab (SQ)

Response rate of Anti-TNFs in IBD patients?

~40%
- Infliximab #1 efficacy
- Adalimumab most convenient (monthly SQ inj.)

Anti-TNF BBWs

1.) Infections (TB, invasive fungal, bacterial, viral, opportunistic)
- require PPD, CXR, HBV/HCV/HIV testing

2.) Malignancy (lymphoma, inc. when combo with AZA)

Selective adhesion molecule (integrin) inhibitor - Drugs

Natalizumab (IV)
Vedolizumab (IV)

Which integrin inhibitor is preferred?

Vedolizumab (a4b7) - only targets T-cells in GI tract

Natalizumab BBW

PML (CNS infection)

IL Inhibitors - Drugs

IL-12, 23: Ustekinumab (IV, then SQ) IL-23: Risankizumab (IV, then SQ)

NOT BIOLOGICS, but act like it - Types

JAK inhibitors Sphingosine 1-Phosphate (S1P) Receptor Modulator

JAK inhibitors BBWs

1. Cancer 2. MACE 3. Thrombosis 4. Infections 5. Death

When does FDA approve use of JAK inhibitors in IBD patients?

Patients who have failed 1 or more Anti-TNFs

General Biologics ADEs

IV: infusion reactions a.) Acute: HA, fever, pruritis, nausea - Premedicate with APAP, Benadryl, IV Steroids b.) Chronic: flu-like symptoms - Premedicate with APAP, short-term steroids SQ: injection site reactions

Mild/Mod Active Crohn’s Diagnosis

- PO without fever, abdomen pain, intestine obstruct - Weight loss < 10%

Mild/Mod Active Crohn's Treatment

PO Budesonide (Entocort) x8 weeks

Mod/Severe Active Crohn's Diagnosis

- Fever >38 C - Weight loss > 10% - Abdomen pain - N/V - Significant anemia - Failed Mild therapy

Mod/Severe Active Crohn's Treatment

a. PO Prednisone 40-60 mg b. Anti-TNF (Inflix/Adalim) +/- AZA (for either)

Severe/Fulminant Crohn's Diagnosis

- High fever >39 C - N/V with obstruction - Cachexia (muscle wasting) - Abscess - Persistent symptoms despite systemic steroid/biologic

Severe/Fulminant Chron's Treatment

a. IV MEPN/Hydrocortisone b. IV Infliximab (after 6 weeks steroid) c. *Surgery

Maintenance Therapy for Crohn's (Remission)

a. AZA if steroid induced remission b. Biologic +/- AZA if biologic induced remission

Perianal disease treatment

*ABX Consider: - Infliximab for closure - Surgery if needed

Mild Active UC Diagnosis

- <4 stools - Intermittent blood - Occasional urgency - Normal Hgb/ESR - Elevated CRP/FC

Mild Active UC Treatment for Distal/Left Sided

a. Topical 5-ASA b. Oral 5-ASA *If 5-ASA failure: a. PO Budesonide (Uceris) x8 weeks

Mild Active UC Treatment for Extensive Colitis

PO 5-ASA +/- Budesonide

Mod/Severe Active UC Diagnosis

- >6 stools - Frequent blood - Often urgency - <75% normal Hgb - Elevated ESR/CRP/FC

Mod/Severe Active UC Treatment

a. PO Budesonide x8 weeks b. Prednisone 40-60mg c. Biologic +/- AZA (for all)

Fulminant Active UC Diagnosis

- >10 stools - Continuous Blood - Continuous Urgency - Transfusion req (Hgb<8) - Elevated ESR/CRP/FC

Fulminant Active UC Treatment

a. IV MEPN/Hydrocortisone b. IV Infliximab c. IV Cyclosporine *Surgery (colectomy) will cure UC

Maintenance Therapy for Mild UC (Remission)

Topical or Oral 5-ASA

Maintenance Therapy for Mod-Severe-Fulminant UC (Remission)

a. AZA if steroid induced remission b. Biologic +/- AZA if biologic induced remission c. AZA or Vedolizumab if Cyclosporine induced remission