IBD 2 - Crohn’s Disease

Question 1

What is CDAI? (1)

Answer 1

Crohn’s Disease Activity Index

Question 2

What factors is the CDAI score based on? (8)

Answer 2

Number of liquid stools
Abdominal pain
General wellbeing
Number of extraintestinal complicatiosn
Use of antidiarrhoeals
Presence of abdominal mass
Haematrocrit
Weight

Question 3

What are the severity range of CDAI? (3)

Answer 3

Remission < 150
Moderate > 220
Severe > 300

Question 4

Outline the treatment regimen for inducing remission in patient with CD. (3)

Answer 4

1st line: Corticosteroids

2nd line: Thiopurines or MTX

3rd line: Biologics

Question 5

Explain the use of corticosteroids in inducing remission in patients with CD. (1)

Answer 5

Offer monotherapy with a conventional glucocorticosteroid (Prednisolone, methylprednisolone or IV hydrocortisone) to induce remission in people with a 1st presentation or a single inflammatory exacerbation of CD in a 12 month period.

Question 6

What are the types of CS preparations used for inducing remission in CD? (3)

Answer 6

1. IV:
   - Severe
   - Hydrocortisone 100mg QDS (can go up to 500mg QDS)
2. Oral:
   - Prednisolone 30-40mg daily (morning)
   - Consider oral Budesonide (Entocort or Budenofalk) if Prednisolone is CI/declined. May be effective in ileal disease due to site of release.
   - Tapering - more severe the exacerbation, slower the schedule should be. Average 5mg / week.
   - May need to adjust / slow down to cover introduction of aza/6mp (3 months to effect)
3. Topical:
   - Suppositories = proctitis
   - Enemas effective up to splenic flexures.

Question 7

Explain the use of Budesonide for inducing remission in a patient with CD. (2)

Answer 7

For people with 1 or more of distal ileal, ileocaecal or right sided colonic disease who decline, can’t tolerate or in whom a conventional glucocorticosteroid is c/i.

Budesonide is less effective than a conventional glucocorticosteroid but may have fewer s/e.

Question 8

Explain the use of Azathioprine or 6-MP as add on treatment for inducing remission in patients with CD. (2)

Answer 8

Aza/6MP considered if there are 2 or more inflammatory exacerbations in a 12 month period or
Glucocorticosteroid dose can’t be tapered.

Question 9

Explain the use of 5-aminosalicylate for inducing remission in patient with CD. (2)

Answer 9

In people who decline, can’t tolerate or conventional glucocorticosteroid is c/i, consider 5-ASA for a first presentation or a single inflammatory exacerbation in 12 month period.

5-ASA is less effective than a conventional glucocorticosteroid or Budesonide but may have fewer side effects than a conventional glucocorticosteroid.

Question 10

Explain the use of biologics as add on treatment for inducing remission in patients with CD. (2)

Answer 10

Used as monotherapy if 1st and 2nd line options are CI or not tolerated.
Can be used with immunomodulators.

Question 11

Explain the use of MTX as add on treatment for inducing remission in patients with CD. (2)

Answer 11

AZA + 6-MP aren’t tolerated / c/i.

Question 12

Explain the prescribing safety of thiopurines. (3)

Answer 12

AZA: Prodrug metabolised by xanthine oxidase to mercaptopurine.

6-MP: Metabolite of AZA, sometimes better tolerated and more effective for some patients.

Assess TPMT activity before offering AZA/MP:
- Don’t offer AZA/6-MP, if TPMT activity is deficient (very low or absent)
- Consider AZA or 6-MP at a lower dose if TPMT activity is below normal but not deficient.

Question 13

What pre-treatment bloods/monitoring for thiopurines? (4)

Answer 13

FBC
LFTs
CRP
U&E/renal function

Question 14

What pre-treatment screening is considered for thiopurines? (4)

Answer 14

Hepatitis B + C
HIV
Varicella
EBV

Question 15

What is the dosing regimen for Azathioprine? (1)

Answer 15

2-2.5mg/kg daily

Question 16

What is the dosing regimen for 6-MP? (1)

Answer 16

1-1.5mg/kg daily

Question 17

What counselling is given to patients on thiopurines? (4)

Answer 17

Blood tests: weekly for 1 month then 3 months.
Avoid direct sunlight
Avoid live vaccines
Increased risk of infection, cancer and bone marrow suppression.
- Patient should be warned about the possibility of bone marrow suppression e.g. infections or unexplained bleeding or bruising
- Should report to Rxer immediately.

Question 18

What are the common interactions of thiopurines? (4)

Answer 18

Allopurinol: High risk of increased toxicity, life threatening reaction.

Warfarin: reduced INR, monitor closely and may take 3 months for effect.

Trimethoprim / co-trimoxazole: Increased risk of thombocytopenia/neutropenia = avoid.

Clozapine: High risk of agranulocytosis = avoid.

Question 19

What are the prescribing safety of MTX? (2)

Answer 19

Use if AZA/6-MP is ineffective or aren’t tolerated.
Rx folic acid 5mg once weekly alongside usually 2 to 3 days after MTX dose.

Question 20

What are the monitoring requirements for MTX? (2)

Answer 20

FBC and LFTs before and every month.

Question 21

What warning should you be aware of MTX? (4)

Answer 21

Weekly dosing
One strength to be Rx only.
Px advised of dose and frequency.
Report signs of blood/liver toxicity and respiratory effects.

Question 22

What are the signs of blood toxicity when taking MTX? (3)

Answer 22

Sore throat
Bruising
Mouth Ulcers

Question 23

What are the signs of liver toxicity when using MTX? (4)

Answer 23

Nausea
Vomiting
Abdominal Discomfort
Dark Urine

Question 24

What are the respiratory s/e of taking MTX? (1)

Answer 24

SOB

Question 25

What are the common adverse effects of MTX? (4)

Answer 25

Bone marrow suppression: - Occurs abruptly. - A clinically significant drop in WCC or platelet count calls for immediate withdrawal of MTX and supportive therapy. Liver toxicity: - Treatment not started or discontinued if any liver function abnormalities develop. Pulmonary toxicity: - Monitor for symptoms, discontinue if pneumonitis suspected. Gastrointestinal toxicity: - Withdraw if stomatitis develops.

Question 26

What factors can increase the risk of MTX toxicity? (3)

Answer 26

Advanced age Renal Impairment Concomittant use with another anti-folate drug e.g. trimethoprim.

Question 27

Give e.g. of common interactions with MTX. (2)

Answer 27

Drugs that reduce renal excretion of MTX e.g. NSAIDs . Drugs with anti-folate activity e.g. Trimethoprim.

Question 28

Explain the effect of TNF-a in CD. (3)

Answer 28

Tumour necrosis factor alpha: - Proinflammtory mediator - Overexpressed in IBD - Partly responsible for chronic inflammatory processes in the intestinal tissue.

Question 29

Explain the general use of biologic therapy in CD. (2)

Answer 29

Inducing remission as monotherapy or in combination with an immunosuppressant.

Question 30

What are biologics? (3)

Answer 30

Large, complex molecules. Chemically synthesised: - Made from protein and other substances that occur in nature. - Manufactured in a living system e.g. modified plant and animal cells.

Question 31

Give e.g. of biologics used in IBD. (5)

Answer 31

Infliximab (Remicade) Adalimumab (Humira) Vedolizumab (CD) - Entyvio Ustekinumab (CD) - Stelara Golimumab (UC) - Simponi Rx by brand

Question 32

Explain the use of Infliximab and Adalimumab in IBD tx. (3)

Answer 32

Treatment options for adults with severe active CD. Whose disease hasn’t responded to conventional therapy OR Who are intolerant of or have c/i to conventional therapy.

Question 33

What pre-treatment checks is considered for Infliximab and Adalimumab? (11)

Answer 33

CXR - TB QuantiFERON Gold Tests - TB Hep B+C HIV Varicella HSV EBV Baseline CRP, FBC, U&Es, LFTs, ANA. Weight (dosing) Vaccine advice Urine sample.

Question 34

What is the main risk associated with using biologics in IBD? (1)

Answer 34

Can alter the immune system. If patient has latent TB it can cause reactivation. Hence, screening must be performed to rule TB before initiation. If identified, TB is treated first.

Question 35

What ongoing monitoring is considered for biologics? (5)

Answer 35

FBC, ESR, CRP, LFTs every 6 months ANA levels - annually

Question 36

When should Infliximab and Adalimumab be given? (2)

Answer 36

As planned course of treatment until tx failure including need for surgery. OR Until 12 months after start of tx, whichever is shorter.

Question 37

What are the c/i of using Infliximab + Adalimumab? (9)

Answer 37

Crohn’s related abscess Moderate to severe HF Possible demyelination / multiple sclerosis TB Lymphoma Recurrent infections Hepatitis B Infection (Adalimumab only) Evidence of active infection.

Question 38

When would you consider stopping or withholding Infliximab + Adalimumab? (6)

Answer 38

Patient presents with an active infection. Transaminases are raised >3xULN Severe injection site reaction Rash Low neutrophil count Ahead of elective surgery

Question 39

What are the s/e of Infliximab + Adalimumab? (9)

Answer 39

Headaches Sore throat Swallowing difficulties Aches and pains in muscles/joints Leg/face swelling Nausea, Diarrhoea, Abdominal pain Worsening heart problem Liver dysfunction

Question 40

How long will it take for the s/e of Infliximab /Adalimumab to disappear? (1)

Answer 40

6 months.

Question 41

What is the main risk associated with taking Infliximab + Adalimumab? (1)

Answer 41

Immunosuppression: - Advise px to tell their doctor immediately if they notice any skin rashes, hives or frequent infections even if they occur several weeks after stopping Infliximab or Adalimumab treatment.

Question 42

What are the long term effects of using Infliximab & Adalimumab? (3)

Answer 42

Higher risk of developing lymphoma. Patients with COPD and heavy smokers, higher risk of cancer. May exacerbate multiple sclerosis.

Question 43

What are the main features of Biosimilars? (2)

Answer 43

Brand Rx only. Switching: same dose/intervals, patient choice and stable clinical response.

Question 44

Explain the cancer risks associated with CD tx. (4)

Answer 44

Higher risk of colon cancer due to IBD. Immunomodulators: - 4x high risk of lymphoma. - Non-melanoma skin cancer - Cervical dysplasia Anti-TNF: - High risk of melanoma Combination of both therapies, higher risk of solid organ malignancy..

Question 45

Outline the process of maintenance therapy of CDs. (3)

Answer 45

Patient specific No tx. Tx: - AZA or 6MP/ MTX - Biologics: - Continue if needed to induce remission.

Question 46

Give e.g. of issues associated with medicine management. (7)

Answer 46

Steroids: BM, K levels + supplements OP: prevention + treatment Patient counselling on AZA/6-MP Monitoring: TMPT interpretation/checking, FBC, LFTs, U+Es. Interactions awareness Pregnancy/conception Screening + vaccination

Question 47

What 5 vaccines should be considered for all patients with IBD? (5)

Answer 47

Influenza (inactivated) vaccine annually. Pneumococcal vaccine Hep. B vaccine (in all HBV seronegative patients) HPV (Human Papillomavirus) Varicella zoster vaccine (if no Hx of shingles or chicken pox if VZV seronegative patients)