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Clinical 2.0 winter > IBD > Flashcards

IBD Flashcards

1
Q

what is ibd

A

chronic inflammatory disorder of the Gi tract

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2
Q

what is indeterminate colitis

A

features of both crohns and ulcerative colitis

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3
Q

what is ulcerative colitis

A

disease confined to bowel wall
rectum then progresses proximally up the splenic flexure then the transverse colon and so on
only in terminal ileum, colon, and rectum

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4
Q

CD and UC pathophysiology

A

genetic predisposition with infectious and immunological responses

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5
Q

what is crohns disease

A

extensive destruction of bowel wall, invasion of adjacent tissues
any part of GI tract

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6
Q

crohns signs and symptoms

A

RLQ tenderness, painful with masses

diarrhea with low grade fever

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7
Q

ulcerative colitis signs and symptoms

A 
rectal bleeding(very few things cause this so prob UC if present with this) and diarrhea
no masses or specific tenderness
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8
Q

goals of therapy for crohns

A

control acute flares
induce remission
maintain remission
avoid or manage ocmplications

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9
Q

non drug therapy for crohns

A

NSAIDS - increased risk of ulcers, worsens inflammation
stop smoking helps as much as drug therapy
avoid foods that trigger
ensure proper nutrition many people wont feel like eating
may have to avoid dairy because the inflammation can cause the lactase enzyme to be shed and produce lactose intolerance

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10
Q

non drug therapy for UC

A

avoid constipating drugs - can cause the colon to expand and lose the ability to regulate your fluid balance
smoking helps

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11
Q

surgery in crohns

A

reserved for strictures and obstructions as theres an increased risk of recurrence at surgical site

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12
Q

ulcerative colitis surgery

A

cured with colectomy

some post op issues

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13
Q

examples of aminosalicylates

A

sulfasalazine

5ASA (mesalamine)

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14
Q

aminosalicylates MOA

A

prostaglandins
decreased cytokines
free radical scavenging

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15
Q

sulfasalazine AE

A

fever, fatigue, headache, diarrhea, dyspepsia
allergic reactions - SJS
hemolysis, agranulocytosis, thrombocytopenia

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16
Q

mesalamine products to target different sites

A

asacol: released in terminal ileum
pentasa: released in small bowel, can open the capsules (increased diarrhea)

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17
Q

aminosalicylate forms

A

oral, enema, suppository

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18
Q

aminosalicylate 5ASA dosing possibility

A

can give any of the qid 5ASA tablets or capsules as a single daily dose

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19
Q

can you give 5ASA in a patient with an ASA allergy

A

yes

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20
Q

how long to assess clinical response to aminosaliccylates

A

4-8 weeks

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21
Q

lowest dose that can be used for aminosalicylate

A

2g/day

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22
Q

if fail 4.8g of one agent what do you do

A

dont switch to diff 5ASA, pick a different agent

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23
Q

aminosalicylate efficacy in UC

A

remission in some
decrease relapse rate in half the patients
most effective in more distal disease

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24
Q

aminosalicylate efficacy in CD

A

benefit is in the colon not ileal disease

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25
corticosteroid suppository used for
proctitis
26
corticosteroid enema used for
``` left sided (sigmoid/rectum) disease for uncontrolled UC ```
27
when would you use topical corticosteroids
mild-mod left sided UC not controlled with 5ASA | budesonide MMX in mild=mod right side colonic and ileal disease
28
when do you use systemic corticosteroids
treatment for mod-severe UC and CD | good for flares
29
onset of systemic corticosteroids
few days to a week if fail 1 week have to use big guns reevaluate in 2 weeks
30
is there long term use of systemic corticosteroids
yes but many problems with long term use, not good to prevent relapse long term patinets just cant get off them
31
efficacy of azathioprine and 6mercaptopurine
induce and maintain remission heals fistulas allows elimination of steroids
32
onset of azathioprine/6mercaptopurine
1 month for improvement | 3 to see if actually working
33
how does azathioprine and 6mercaptopurine work
induces t cell apoptosis
34
describe the break down of sulfasalazine
the diazo bond is cleaved by bacteria into sulfapyridine (responsible for the AE) which is rapidly absorbed into circulation form the colon
35
aminosalicylates are not the same as
cox 2 inhibitors
36
why is it so important to ensure adherance to aminosalicylates
once you go beyond this the next drugs have big time toxicity so want to keep on 5ASA as long as possible
37
problem with buesonide MMX
maintaining remission wiht it alone
38
what is thiopurine methyltransferase
major regulator of 6 TG concentration
39
____ TPMT activity leads to preferential metabolism of 6 TG (increase efficacy and toxicity)`
low
40
how is thiopurine methyltransferase enzyme activity determined
genetically | polymorphism
41
exmplain azathioprine breakdown
breaks down into 6mercaptopurine then into thioinsinic acid | TPMT breaks that into 6methylmercaptopurine or it breaks down into thioguanine metabolite
42
explain TPMT testing
becoming the standard of care | 17 mutant allelles but only tests for the most common 3
43
problem with TPMT testing
patients with a recent blood transfusion willhave other peoples RBC so may seem like they have normal TPMT when its actually low have to wait 3 months for the RBC to die???
44
can you rely on the TPMT testing to predict who will have severe myelosuppression from azathiopirine
no | STILL HAVE TO DO BLOOD TESTS REGULARLY to ensure myelosuppresssion doesnt happen
45
very important drug interaction to remember
azathiopurine and allopurinol
46
SE of AZA 6MP
``` neutropenia atypical infection pancreatitis - first 6 weeks watch for ab or back pain and vomiting skin rash small increase in maignancies ```
47
do you need PJP prophylaxis when on AZA
not unless also on high dose steroids
48
CBC monitoring for aza
weekly for first month then every 2 weeks for month 2 and 3 then every month
49
what do you ask someone getting a drug that needs blood work
when theyre getting blood work done not if
50
methotrexate is used fr
CD similar results to aza somewhat faster onset but still need a month trial not used in UC except if refractory to aza
51
methotrexate contraindicated in
pregnant women
52
AE of methotrexate
neutropenia atypicla infections liver dysfunction pneumonitis
53
dosing with immunomodulator methotrexate
no set dosing
54
cyclosporine use
severe active UC refusing surgery or have bad surgical risks limited to 6 months use to brudge patients to aza
55
if a patient fails on methylprednisolone and refuses surgery we use
anti TNF
56
how does infliximab work
antibody that binds to tumor necrosis factor and induces t cell apoptosis
57
infliximab used for
severe active or fistulizing CD active UC best data for remission in fistulizing crohns
58
dosing of infliximab and time for response
3 doses at 0,2,6 weeks | see a response in the first week
59
how long do people stay on infliximab
data for up to 1 year but some people on it indefinitely although we are still learning how long its efficacy and safety lasts
60
what to do if not responding to induction doses of infliximab
no benefit in continuing into maintenance therapy with the same agent
61
what to do if not responding to the first anti tnf agent
evidence of benefit in trying another one though response is lower than in the anti TNF naive
62
infliximab SE
nausea URT infections GI pain infections - impairment of IS, TB reactivation, too rapid closure of fistulas allergic reactions infusion related reactions - headache, flushing, dizzy
63
infliximab long term issues
``` infections - tuberculosis malignancies lupus like syndrome demyelinatin - optic neuritis, MS pancytopenia hepatic lymphomas in young people - hepatosplenic T cell lymphomas cases were fatal leukemias new onset psoriasis ```
64
impact of antibody formation to murine component of infliximab
loss of response | need to increase dose or frequency
65
ways to prevent infliximab antibody formation
intermittent use increase risk of antibodies so use continuously i guess dont start on infliximab unless patient agrees to go on aza pretreat with steroids if just starting treatment
66
anti TNF questions for the pahrmacist
have they previously been exposed to antiTNF are pretreatment steroids required mantoux test or chest xray (to test for TB), baseline LFT and hepatitis viral studies been performed
67
antidiarrheals for supportive therapy
loperamide and codiene - cna use prior to sports to decrease ileostomy drainage stop temporarily whrn CD deteriorates quickly never use in severe disease as increases risk of toxic megacolon cholestyramine for bile salt diarrhea
68
drugs for inducing remssion in UC
``` aminosalicylates with mild-mod corticosteroids cyclosporine antiTNF vedolizumab ```
69
drugs for maintaining remission in UC
aminosalicylates with mild-mod disease AZA,6MP, maybe MTX anti TNP vedolizumab
70
monitoring UC therapy
scoring systems of disease activity rectal bleeding and diarrhea, frequency of stools/day anemia, low albumin, increased ESR, fever, ab pain - serious fever new ab pain - see doctor adherence very important - esp with 5ASA
71
drugs for inducing remission in crohns
corticosteroids | anti TNFs
72
drugs for maintaining remission in crohns
``` aminosalicylate? budesonide? aza, 6MP, methotrextae antiTNF metronidazole, ciprofloxacin sometimes in ileal or colonic never use cyclosporin ```
73
monitoring crohns therapy
heterogenous features heal fistula, decrease in diarrhea and ab pain weight, hemoglobin, endoscopic features frequency of needing support therapy - ex loperamide frequency of missing school or work
74
whats the main treatment for mild - mod UC
5ASA
75
difference between crohns and ulcerative colitis
crohns: occurs in the colon and lower SI commonly but can affect entire GI tract, can comprise multiple separate areas of inflammation, can form fissures UC: affects only sigmoid colon and rectum, continuous patch of inflammation, damages inner lining of intestinal wall

Clinical 2.0 winter (28 decks)

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