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IBD Flashcards

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1
Q

Idiopathic IBD categories

A

Ulcerative colitis

Crohn’s disease

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2
Q

Ulcerative colitis

A

Mucosal inflammatory condition affecting the rectum and colon

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3
Q

Crohn’s disease

A

Transmural inflammation of any part of the GI tract, mouth to anus

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4
Q

Clinical findings for UC

A 
Continuous inflammation (very common)
Toxic megacolon
Pseudopolyps
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5
Q

UC histology

A

Nontransmural

Crypt abscesses

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6
Q

Depth of UC ucleration

A

Superficial

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7
Q

Is UC a risk factor for colorectal cancer?

A

Yes

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8
Q

Clinical findings for CD

A

Patchy cobblestone appearance
Perianal involvement
Fistula, perforation, or strictures
Malabsorption/malnutrition - vitamin deficiencies; possible growth retardation

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9
Q

Depth of CD ulceration

A

May extend to submucosa or deeper

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10
Q

Histology of CD

A

Transmural lesions

Granuloma

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11
Q

Extraintestinal complications (more common in CD)

A 
Spondylarthritis
Peripheral arthritis
Ocular
Primary sclerosing cholangitis
Anemia
C diff
Hypercoagulability
Malabsorption
Thromboembolic disease 
Osteoporosis
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12
Q

Thromboembolic disease in CD

A

Risk for VTE is three-fold higher than in general population

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13
Q

How is osteoporosis caused by IBD?

A

D/t systemic inflammation effects on bone, malabsorption of Vit D, and glucocorticoid use; bisphosphonates are the preferred drug of treatment

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14
Q

Smoking in UC

A

Nicotine offers a protective mechanism
The likelihood of a smoker developing UC is less than half that of a non-smoker
Patients with UC who stop smoking often relapse

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15
Q

Transdermal nicotine patches and UC

A

Shown improvement in disease remission rates but are not recommended as a standard of care

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16
Q

Smoking and CD

A

Ppl who smoke are 2x as likely to have CD

Patients who stop smoking will see reduction in severity of their condition

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17
Q

Assumed etiologies for IBD

A 
Infectious
Genetic
Environmental
Psychologic
Immunologic
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18
Q

Genetics and IBD

A

CD is common among relatives
1st degree relatives are 13x more likely to suffer from IBD
Genes have been identified for UC and CD

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19
Q

Environment and IBD

A

No clear connection to diet

NSAID use - PG inhibition appears to impair the protective mechanism of the mucosal barrier in the GI tract

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20
Q

Psychology and IBD

A

Clear association between mental health and remissions/flares

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21
Q

Immunology and IBD

A

Cytokines - inappropriate T cell response to intestinal flora
TNF-alpha - activates coagulation and promotes granuloma formation (production enhanced in patients with CD)

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22
Q

Mild IBD

A

+/- blood in stool
No systemic sx
Normal ESR

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23
Q

Moderate IBD

A

+/- blood in stool
Minimal systemic sx
Normal ESR

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24
Q

Severe

A

+ blood in stool
+ systemic sx
Increased ESR (> 30)

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25
CDAI
Chrone's disease Activity Index Mostly done in trials Measures CD
26
IBDQ score
QOL
27
Genetics tests for IBD
Prometheus Labs | May indicate how severe a patient's dz will be
28
Diagnosis of IBD
Pt sx PE Labs Radiographic/endoscopic findings
29
Labs for IBD diagonsis
Compares carious IgG and IgM in patient with a database of IBD patients Not extremely accurate
30
Non-pharm treatment of IBD
Nutrition (avoid exacerbating foods, use parenteral nutrition if needed) Surgery (indications include uncontrolled disease despite max therapy, presence of complications or presence of premalignant changes)
31
Pharm treatment of IBD
``` Aminosalicylates Corticosteroids immunosuppressants Cipro/flagyl TNF-alpha Humanized monoclonal antibody to alpha-4 integrin Tofacitinib ```
32
Aminosalicylates
Balsalazide Osalazine Sulfasalazine Mesalamine
33
Aminosalicylates MOA
Modulates leukotrienes to inhibit inflammatory response
34
Aminosalicylates time to effectiveness
2-4 weeks, treat for 6-8 weeks at full treatment dose
35
Aminosalicylates MD
50% treatment dose
36
Aminosalicylates and monitoring
SCr prior to starting therapy and periodically thereafter d/t risk for nephrotoxicity
37
Balsalazide site of action
Colon
38
Osalazine site of action
Colon
39
Osalazine ADR
Dose-related diarrhea
40
Sulfasalazine ADR
N/V Ab pain CI: sulfa allergy
41
Mesalamine general
Easier to tolerate than sulfasalazine
42
Mesalamine brands and site of action
``` Rowasa: rectum; terminal colon Delzicol/Asacol HD: distal ileum; colon Canasa: rectum Pentasa: small bowel; colon Lialda: colon Apriso: colon ```
43
Mesalamine monitoring
folic acid level
44
Mesalamine DDI
``` Antacids H2RAs PPIs **May cause premature relase of delayed release products Preg risk cat D ```
45
Corticosteroids MOA
Inhibit inflammatory mediator release (cytokines)
46
Corticosteroids
Prednisone Methylprednisolone IV Budesonide
47
Budesonide bioavailability
Poorly absorbed w/limited bioavailability d/t an extensive 1st pass metabolism by the liver allowing it to produce therapeutic benefit with reduced systemic toxicity
48
Budesonide
Enterocort EC - for CD in the terminal ileum or right colon (12 week treatment then taper) Uceris - UC (8 week treatment then taper)
49
Budesonide monitoring
BMD yearly, receive vit D and calcium if long term use required
50
Immunosuppresants
Azathioprine, 6-MP CsA MTX
51
Azathioprine, 6-MP MOA
Antagonizes purine metabolism causing immunosuppresion
52
how long until a patient on AZA, 6-MP sees a benefit
3 months (use something quicker in the meantime)
53
AZA, 6-MP monitoring
``` Hg WBC Plts LFTs Amylase TPMT testing may help prevent toxicity ```
54
CSA MOA
Inhibits production and release of IL-2 causing immunosuppression
55
CsA IV use
Severe UC and CD unresponsive to IV steroids
56
MTX use
CD only
57
MTX MOA
Anti-inflammatory and immunosuppression through irreversible dihydrofolate reductase inhibition
58
MTX monitoring
CBC LFTs SCr
59
MTX DDIs
PPIs - appears to only impact high dose MTX used in chemo regimens
60
Cipro/flagyl use
CD only - Fistulizing Crohn's: abx x 3 months - Potential role in post-op CD pt (pouchitis)
61
Cipro/flagyl MOA
Benefit is thought to be through inhibiting bacterial stimulation of the inflammatory process
62
TNF-alpha antagonists MOA
Monoclonal ab that bind to human TNF-alpha thereby interfering with endogenous TNG alpha activity
63
TNF-alpha antagonists BBW
- Serious infx (including tuberculosis, invasive fungal and other opportunistic infxns), some with fatalities, have been reprted in patients receiving TNF-blocking agents - Pts should be evaluated for TB risk factors and latent TB infxn (w/ a tuberculin skin test) prior to therapy. Tx of latent TB should be initiated before use. Pts with initial neg TB skin tests should receive continued monitoring for TB throughout treatment
64
TNF-alpha antagonists
Infliximab Adalimumab Certolizumab
65
Infliximab uses
Adults/pediatrics: CD or UC | Adults: fistulizing CD
66
Infliximab ADR
Infusion rxn treated with benadryl and APAP (pre-med for future doses)
67
Adalimumab uses
Adults/peds: CD/UC
68
Certolizumab uses
CD in adults only
69
TNF-alpha antagonists monitoring
``` CRP Fecal calprotectin Lactoferrin Albumin Antidrug ab Anti-TNF drug level (if pt loses response to drug) ```
70
TNF-alpha antagonists: if pt loses response with subtherapeutic drug levels AND low or no abs?
Increase anti-TNF and/or decrease interval | Consider adding thiopurine/MTX if not already on
71
TNF-alpha antagonists: if patient loses response with subtherapeutic drug levels and high ab levels
Switch to different TNF-alpha antagonists
72
TNF-alpha antagonists: if patient loses response with therapeutic drug levels
switch to vedolizumab w/ or w/o immunosuppressant (if CD; if UC, DC drug)
73
Humanized monoclonal ab to alpha-4 integrin MOA
Inhibit leukocyte adhesion and migration (vedolizumab in GI tract only)
74
Humanized monoclonal ab to alpha-4 integrin uses
Inducing and maintaining clinical response and remission in adult patients with mod-severe active CD (natalizumab and vedulizumab) or UC (vedolizumab) with an inadequate response to, or are unable to tolerate conventional CD/UC therapies and TNF-alpha antagonists
75
What must be up-to-date before starting Humanized monoclonal ab to alpha-4 integrins
Immunizations
76
Humanized monoclonal ab to alpha-4 integrins
Natalizumab | Vedolizumab
77
Natalizumab ADR
Progressive multifocal leukoencepholopathy in MS | Severe cholestatic injury
78
Natalizumab monitoring
LFTs (esp during first week of therapy)
79
Vedolizumab ADR
HA Arthralgia Nasopharyngitis
80
Tofacitinib (Xeljanz)
Janus Associated Kinase inhibitor approved for RA | Currently being studied in UC patients with mod-severe disease non-responsive to other treatment
81
Vaccines for IBD
``` Flu PCV13 or PPSV23 Zoster Varicella Yellow fever Hep B Meningococcal ```
82
Flu vaccine and IBD
Annually | If on immunosuppressant: non-live trivalent
83
PCV13 or PPSV23 vaccine and IBD
If on immunosuppressant | Should have PPSY23 booster 5 years after 1st dose
84
Zoster vaccine and IBD
Not on immunosuppressants or on low dose MTX, AZA, or 6-MP | Not recommended if on anti-TNF therapy
85
Varicella vaccine and IBD
Assess for prior exposure and vaccinate if naive PRIOR to initiating immunosuppressant therapy
86
Yellow fever vaccine and IBD
Vaccinated prior to travel Assessed before travel -If highly immunosuppressed - should not travel -To stop immunosuppressants in order to get vaccine - wait 3 months before vaccination; then wait at least 4 weeks to restart immunosuppressant
87
Hep B vaccine and IBD
HBV can be re-activated in an immunocompromised patient Test for HBV infection prior to starting treatment Check for immunity to HBV and vaccinate if not immune prior to starting treatment 1-3 months after vaccination, check a titer to be sure patient is immune Check a titer every 1-2 yr thereafter; give a single booster shot if necessary
88
Health screenings in IBD
Cervical cancer - annual Depression/anxiety screening Melanoma Non-melanoma squamous cell cancer screening - > 50 yo on immunosuppressants Osteoporosis - those with conventional risk factors should be screened at the time of diagnosis and periodically after diagnosis

GI/Hepatic (7 decks)

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