IBD Treatments

Question 1

Treatment of ulcerative colitis

Answer 1

5-ASA, steroids, azathioprine/6-mercaptopurine, cyclosporine, infliximab, surgery - curative

Question 2

Treatment of Crohns

Answer 2

5-ASA, steroids, azothioprine/6-mercaptopurine, methotrexate, infliximab, non-curative surgery

Question 3

Which drug is the first line in treatment of UC to induce and maintain remission and prevent colonic cancer?

Answer 3

ASA’s ie mesalazine (minimal use in Crohn’s)

Question 4

Mechanism of action of ASA’s?

Answer 4

Anti-inflammatory, anti-folate (inhibit synthesis of inflammatory mediators like prostaglandins, thromboxane, platelet activating factor), scavenger of oxygen radicals

Question 5

Which was the first ASA on the market?

Answer 5

Sulfasalazine

Question 6

SE’s of sulfasalazine?

Answer 6

Rash fever, leucopenia, agranulocytosis, male infertility, male infertility, orange discolouration of bodily fluids

Question 7

What is the commonest ASA used? Name 2 others

Answer 7

Mesalazine - use orally or topically. Others include olsalazine and balsalazide

Question 8

SE’s of ASA’s?

Answer 8

Diarrhoea, headache, nausea, rash, monitor renal function

Question 9

What does corticosteroids do in IBD?

Answer 9

Induces remission, potent anti-inflammatory

Question 10

What effects does ACTH have?

Answer 10

Affects water and electrolyte balance via mineralocorticoids. Affects protein and carb metabolism via glucocorticoid function (anti-inflammatory and immunosuppressive). Inactivates NF-KB and AP-1; prevents stimulation of prostaglandins, leukotrienes, cytokines, platelet activating factor

Question 11

Prescribing issues with corticosteroids?

Answer 11

Not for long term use, do not stop suddenly, give bone protection (calcium and bisphosphanates)

Question 12

Examples of corticosteroids?

Answer 12

Prednisolone, budesonide, beclometasone, hydrocortisone (IV), hydro and pred can be used topically

Question 13

Immunosuppressants used in IBD (3)?

Answer 13

Azothioprine, ciclosporin, methotrexate

Question 14

Examples of thiopurines?

Answer 14

Azothioprine, 6-mecraptopurine

Question 15

When are thiopurines used?

Answer 15

When 5-ASA not well tolerated; in severe relapsing disease; when 2 or more corticosteroid treatments were need in 12 months or relapsing disease below 15mg steroid or within 6 months of stopping steroid, following ciclosporin

Question 16

What is azothioprine metabolised to?

Answer 16

6-mercaptopurine which can be used on its own to avoid some of the side-effects. Is also steroid-sparing

Question 17

SE’s of thiopurines?

Answer 17

Allergic, bone marrow suppression, leukopenia, hepatotoxicity

Question 18

What metabolises thiopurines and why is this relevant?

Answer 18

Thiopurine methyltransferase (TPMT). TPMT deficiency patients at higher risk of bone marrow suppression

Question 19

What does ciclosporin do?

Answer 19

Calcinuerin inhibitor (prevents expansion of T-cell subsets)

Question 20

Which condition is ciclosporin used in?

Answer 20

Ulcerative Colitis

Question 21

When would you consider colectomy?

Answer 21

If no response to IV steroid after colitis

Question 22

How would you prescribe ciclosporin?

Answer 22

2mg/kg daily IV or 5-6mg/kg daily PO

Question 23

SE’s of ciclosporin?

Answer 23

HT, infection renal impairment, increase risk of seizures if IV, if they have low cholesterol or magnesium; gum hypertrophy and hirsuitism

Question 24

How does methotrexate work?

Answer 24

Anti-inflammatory; inhibits cytokine and eicosanoid synthesis. Induces and maintains remission in CROHN’S disease. 2nd line immunosuppressive after AZA

Question 25

SE's of methotrexate?

Answer 25

GI - nausea, vomiting, diarrhoea (give folic acid weekly), hepatotoxicity, blood dyscrasias

Question 26

How is methotrexate given?

Answer 26

Weekly 2.5mg tablets. Can be given IM or SC as more effective but oral more convenient. Monitor LFT's and FBC

Question 27

What does infliximab do

Answer 27

Chimeric anti-tnF antibody, targets membrane-bound TNF and kills host cell by complement induced lysis, ant-inflammatory

Question 28

Indications for infliximab?

Answer 28

Severe active crohn's or where ciclosporin cannot be used in UC

Question 29

How would you prescribe infliximab?

Answer 29

IV, 5mg/kg in 250ml normal saline over 2hrs, weeks 0, 2 and 6, then every 8 weeks.

Question 30

SE's of infliximab?

Answer 30

Delayed hypersensitivity, chest infections

Question 31

MoA of adalimumab?

Answer 31

Targets TNF-alpha

Question 32

Indications for adalimumab?

Answer 32

Severe active crohn's disease

Question 33

How is adalimumab given?

Answer 33

Subcut 80mg to 40mg

Question 34

Which antibiotics would you use for infectious complications?

Answer 34

Metronidazole or ciprofloxacin

Question 35

Indications for metronidazole and ciprofloxacin in IBD?

Answer 35

Infectious complications, perianal CD, prevention of postoperative recurrence of CD, pouchitis in UC

Question 36

Treatment in active ulcerative colitis?

Answer 36

5-ASA and corticosteroids, then ciclosporin and inliximab, then colectomy

Question 37

Maintenance treatment in UC?

Answer 37

5-ASA and azathiprine if needed

Question 38

Treatment in active crohn's?

Answer 38

Corticosteroids, then azathioprine and monoclonal antibodies

Question 39

Maintenance treatment in Crohn's?

Answer 39

Azathioprine, methotrexate and monoclonal antibodies if all else fails