IBS/IBD Flashcards
1
Q
what has Contributing Factors: Genetics, motility factors, inflammation, colonic infections, mechanical irritation to local nerves, stress
A
IBS
2
Q
what has Lower abdominal pain, disturbed defecation, and bloating with absence of structural or biochemical explaining factors
A
IBS
3
Q
what has -Diarrhea Symptoms > 3 stools/d Extreme Urgency Mucus passage -Constipation Symptoms < 3 stools/wk Straining Incomplete Evacuation -Psychological Depression Anxiety
A
IBS
4
Q
what are 3 comorbid conditions with IBS
A
Fibromyalgia
Functional dyspepsia
Chronic Fatigue Syndrome
5
Q
MANNING Chronic Or recurrent abdominal pain > __months with 2 or more of the following:
A
6 mo Ab pain relieved by defecation Ab pain associated with more freq stool Ab distention Feeling of incomplete evacuation after defecation Mucus in stools
6
Q
ROME III
Recurrent abdominal pain or discomfort > __ days/month in the last __ months associated with 2 or more of the following:
A
3 days for 3 mo
Relieved with defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool
7
Q
for constipation predom IBS how do you treat? 4
A
Stress management and patient education
Increase dietary fiber and fluid
Next add bulk forming laxative and consider antispasmodics
Add serotonin-4 agonist (Tegaserod)
8
Q
for diarrhea predom IBS how do you treat? 4
A
Stress Management and Patient Education
Lactose and caffeine free diet as well as avoiding other causative foods
Add loperamide or another antispasmodic
Add 5-HT3 antagonist (Alosetron)
9
Q
Mucosal inflammatory condition
Confined to rectum and colon
A
Ulcerative colitis
10
Q
Transmural inflammation of GI tract
Can affect any part of GI tract
A
Crohns
11
Q
Inflammation is limited to the mucosa; continuous pattern of involvement
A
UC
12
Q
what has symptoms of Bloody diarrhea and abdominal pain = cardinal symptoms
Severe cases: fever, anorexia, weight
A
UC
13
Q
what has Autoimmune pathophysiology and Inflammation occurs throughout the full thickness of the bowel wall; skip pattern of involvement; strictures, fistulas, ulcers
A
Crohn’s
14
Q
what has cardinal symptoms of diarrhea and abdominal pain and Weight loss, vomiting, fever, perianal discomfort, bleeding = common complaints
A
Crohns
15
Q
what bacteria 1st detected in 1980s in intestinal tissue of Crohn’s disease pts
A
Mycobacterium avium subspecies paratuberculosis (MAP)
16
Q
what bacteria is inc in IBD? and what has no beneifit?
A
Increase in pathogenic bacteria Bacteroides Escherichia coli Decreased beneficial bacteria Bifidobacterium Lactobacillus species
17
Q
what is smoking protective in?
A
UC
18
Q
what does smoking make worse?
A
CD
19
Q
what drugs should you avoid in IBD - 3 types
A
Opiates Reduce GI Motility NSAIDS Worsen IBD by disrupting mucosal barrier Antidiarrheals Loperamide, Diphenoxylate/Atropine Risk of Precipitating Toxic Megalocolon
20
Q
what diet improves UC? exacerbates?
A
NONE
21
Q
what dietary measure should you avoid in UC exacerbation
A
fiber
22
Q
what should you take during remissions of UC
A
Metamucil 1-2 x day
23
Q
how do you treat mild to moderate UC - 4 options
A
-Sulfasalazine 4-6 g/day OR
-Mesalamine 4.8 g/day OR
-Aminosalicylate at dose equivalent to mesalamine 4.8 g/day
-OR if Distal Disease
Mesalamine Enema/Suppository
Corticosteroid Enema
24
Q
what do you do for remission of mild to mod UC - 2 options
A
Reduce dose by half OR
With enema/ suppository: Reduce frequency to q 1-2days
25
what do you use to treat mod - severe UC
Sulfasalazine 4-6g/day OR Mesalamine 3-6g/day
| Plus Prednisone 40-60mg/day
26
how do you treat remitted mod-severe UC
Taper prednisone, then reduce sulfasalazine or mesalamine after 1-2 months to approximately half
27
how do you treat refractory mod-severe UC? what should you consider if no response
Add Azathioprine or Mercaptopurine (6-MP) OR
| Consider Infliximab if no response
28
how do you treat Severe or Fulminant Ulcerative Colitis?
Hydrocortisone IV
29
how do you treat remitted Severe or Fulminant Ulcerative Colitis
Change to prednisone add sulfasalazine or mesalamine
30
if, in Severe or Fulminant Ulcerative Colitis, there is no response for 5-7 days...
Cyclosporine IV 4 mg/kg/day
| If no response, patient candidate for colectomy
31
can surgical resection cure UC?
yes High-grade dysplasia, suspected cancer
| Pts with severe disease requiring high-dose steroids that can’t be tapered after 6-12 months
32
what is used in maintenance of UC? 2 options
Aminosalicylates and/or AZA or 6-MP
Alternative Infliximab 5mg/kg q 8 weeks
33
what are the nutritional measures for CD? 3
Limit fiber with cramping and diarrhea
Decrease fat intake when steatorrhea
Multivitamin with minerals daily
34
how do you treat Mild-Moderate Crohn’s if its in ileocolonic or colonic
Sulfasalazine 3-6 g/day or
| Oral mesalamine 3-4 g/day
35
how do you treat Mild-Moderate Crohn’s if its perianal?
Sulfasalazine 3-6 g/day or
Oral mesalamine 3-4 g/day and/or
Metronidazole 10-20 mg/kg/
36
how do you treat Mild-Moderate Crohn’s if its in the sm bowel?
Oral mesalamine 3-4 g/day or
Metronidazole 10-20 mg/kg/day or
Budesonide 9mg/day
37
how do you treat mod-severe crohns?
add prednisone to mild-mod
38
if crohns is refractory or fistulizing
add infliximab
39
if crohns is not responsive after adding infliximab...
Adalimumab
Natalizumab
Certolizumab
40
when do you taper prednisone in crohns? and add?
after 2-3 weeks
| Add AZA, 6-MP or MTX
41
how do you treat severe-fulminant crohns?
hydrocortisone IV
42
how do you treat if severe-fulm crohns doesnt respond to hydrocortisone
Cyclosporin IV
43
what is first line maintenance for crohns... 2nd and 3rd...
Azathioprine/6-MP
Infliximab 5 mg/kg IV q wk x 6, then q 8 weeks
Methotrexate 25mg IM up to 16 weeks followed by 15mg IM weekly
44
what is the MOA of Sulfasalazine (Azulfidine)
Metabolized by intestinal bacteria to to the active component 5-aminosalicylate (5-ASA) and sulfapyridine (mesalamine)
45
what are the contraind of Sulfasalazine (Azulfidine)? 2
Salicylate hypersensitivity
| Renal impairment- Monitor SCr
46
what are the ADRs of Sulfasalazine (Azulfidine)? lots
- N/V, heartburn, anorexia
- HA
- Hypersensitivity rxns (rash, fever)-Do not use in pts with sulfa allergy
- Blood disorders (anemia, thrombocytopenia, granulocytopenia)
- Can impair folic acid absorption
- Idiosyncratic rxns (hepatocellular injury, agranulocytosis, lupus-like phenomena)
- Low sperm counts
47
what is mesalamine?
aminosalicylate
48
what are the ADRs of mesalamine?
Local itching and mild rectal irritation with topical enemas
| Idiosyncratic rxns: pleuropericarditis, pancreatitis, nephrotic syndrome
49
how id mesalamine given?
Mesalamine or suppositories for rectosigmoid disease
| Delayed release formulations of mesalamine for Crohn’s ileitis
50
what is the MOA of corticosteroids?
Anti-inflammatory effects
Improves Symptoms
Improves disease severity
51
how do we taper corticosteroids?
Taper by 5mg/wk prednisone or equivalent
52
how long should it take for corticosteroids to work?
7-14 days
53
what does the Inability to taper is indicate
indication for amtimetabolite and/or infliximab therapy
54
Parenteral steroid indicated in pts ...
failing to respond to 7-14 days of high dose oral prednisone or equivalent
55
what do you need to monitor for in corticosteroids
Glucose intolerance/ metabolic abnormalities
Hyperkalemia
Hyponatremia
glucose
Greater risk for adrenal insufficiency and infections
N/V
Postural hypotension
56
what is long term tx of corticosteroids? what do you need to do?
>3 mo bonedensity scan and annual eye exam
57
what are 2 Immunosuppressives
6-Mercaptopurine (6-MP)
Azathioprine (Imuran)
Pro-drug metabolized to 6-MP
58
what is the adv of Immunosuppressives
Maintenance therapy that is less toxic than chronic steroid therapy
Steroid-sparing achieve or maintain control and allow reduction or discontinuation of steroids
59
what is the MOA of Immunosuppressives
Antagonizes purine metabolism; inhibits DNA, RNA and protein synthesis
60
what is the disadv of Immunosuppressives
delay in onset
61
what are the numerous ADRs.... BM, other inc risks? GI? Other? Infections?
```
Bone marrow suppression 2-5%
Dose related
Managed by dose reduction/withdrawal
Leukopenia, thrombocytopenia, pancytopenia
Risk of lymphoma
4 fold increase
Pancreatitis 1.3-3.3%
Dose independent
Occurs within 3-4 weeks of start
Resolves with stopping drug
GI effects
N/V, abdominal pain
Occurs early, improves with time or with dose reduction
Other
Fever, rash, arthralgias
Dose independent
Infections
Disseminated CMV, herpes zoster, pneumonia, Q fever, viral hepatitis
Occur without leukopenia
Increased risk if combined with steroids
```
62
what are the drug int of Immunosuppressives
```
Inhibition of metabolism leading to increased myelosuppression
Sulfasalazine, mesalamine
Allopurinol
Aspirin
Furosemid
```
63
what is mtx?
immunomodulator
64
what is the MOA of mtx
Folic acid antagonist with anti-inflammatory effects (affects immune system??)
65
what is the good thing about mtx
Reduces steroid needs
| Improves disease control
66
what are the adr's of mtx.... lots!
```
Nausea
Elevated transaminases
Leukopenia
N/V
Hypersensitivity pneumonitis (rare)
Hepatic fibrosis
Most significant in long term therapy
Risk with >1500 mg total cumulative dose and daily dosing
DC if moderate/severe fibrosis or cirrhosis found on biopsy
```
67
what is contrind for mtx?
Absolute contraindication in pregnancy (Category X)
Stop therapy 3 months prior to conception
Folate supplementation prior to conception
Contraindicated in breastfeeding
68
what are 2 cyclosporins?
neoral and sandimmune
69
what is the MOA of cyclosporins
inhibits production and release of IL-2 inhibits activation of T-lymphocytes
70
what is recommended for cyclosporins in tx? and remission?
Concomitant IV steroids recommended
Cyclosporin alone unable to maintain remission
Requires “bridging” with AZA or 6-MP
Convert IV to PO
PO dose is 2x IV dose
Wean off cyclosporin and steroids over next few months
71
cyclosporins toxicity?
```
HTN
Hypertrichosis
Electrolyte abnormalities
Nephrotoxicity
Opportunistic Infections
Requires PCP prophylaxis
```
72
what is the MOA of Tacrolimus (Prograf)
inhibits T-lymphocyte activation
| Fungus (streptomyces)
73
what is ADRs of Tacrolimus (Prograf)
```
Adverse Reactions: Tend to resolve with dose reductions
HA
Increased serum creatinine
Nausea
Insomnia
Leg cramps
Paresthesias
Tremors
```
74
what are 3 monoclonal ab?
infliximab, adalimumab, natalizumab
75
what is the MOA of infliximab?
Monoclonal antibody that binds to TNF-alpha
| Inhibits inflammatory cytokines, inhibits leukocyte migration and activation of neutrophils
76
infliximab contraind?
```
NYHA class III/IV heart failure
Dose should not exceed 5mg/kg in other pts with congestive heart failure
Hepatitis
Reactivation of hepatitis B
Autoimmune hepatitis
Discontinue use with LFTs 5x ULN
```
77
ab to infliximab what happens?
Increased risk of infusion rxn, shorter duration of response
| regularly scheduled less immunogenic than episodic
78
what infections may infliximab tox cause?
Bacterial, mycosal, mycobacterium
| Higher TB rates with more extrapulmonary involvement
79
what infusion rxn may infliximab tox cause?
During or after (1-2 hrs)
HA, dizziness, nausea, erythema at site, flushing, fever, chills, chest pain, cough, dyspnea, pruritis
Mechanism unclear- not IgE type 1
Doesn’t occur till after 1st infusion; not at every infusion
80
what delayed hypersensitivities may infliximab tox cause?
3-14 days after infusion
Myalgia, arthralgia, fever, rash, pruritis, dysphagia, urticaria, HA
Resolve spontaneously or require steroids
Prednisone 40mg PO or methylprednisolone 100mg IV 30 min before
81
what is rare with autoab to infliximab?
Development of drug-induced lupus rare
| Reversible with DC
82
what malignancy may come from infliximab tox?
Malignancy and lymphoproliferative disorder
| Longstanding CD and tx with immunosuppression more likely to develop lymphomas
83
what is the MOA of adalimumab?
recombinant fully-human immunoglobulin-1 anti-tumor necrosis factor (TNF)-alpha monoclonal antibody
84
what should you do before tx with adalimumab
eval for TB
85
what is the BB warning on adalimumab
TB, invasive fungal, other opportunistic infections
86
what are other adrs of adalimumab
Rash, injection site rxn, HA, URI, development of autoantibodies to drug, development of anti-nuclear antibodies (ANA)
Risk of reactivating hepatitis B
87
what is true aboud natalizumab? approved for? devp for?
Approved by FDA on 1/14/08 for “moderate to severe Crohn’s in pts with evidence of inflammation who have had inadequate response to, or are unable to tolerate conventional therapies
Pts must be enrolled in special restricted distribution program
Crohn’s Disease-Tysabri Outreach Unified Commitment to Health (CD-Touch) Prescribing Program
Originally approved June 2006 for MS
88
what is the moa of natalizumab?
recombinant immunoglobulin-4 monoclonal antibody
89
when do you DC natalizumab?
if no response in 12 wks, or steroids not tapered within 6 mo
90
dont admin natalizumab with?
other immunosuppressants (6-MP, azathioprine, MTX, cyclosporin, or inhibitors of TNF)
91
what is the major adr of natalizumab?
progressive multifocal encephalopathy
92
what is metronidazole used for in IBD?
```
Indications:
For treatment of ileocolitis or colitis
Failure to respond to sulfasalazine
For treatment of abscesses, rectovaginal fistulas, proctocolectomy wounds
Low dose maintenance
```
93
what are the adrs of metronidazole?
GI upset, metallic taste, paresthesias, antabuse-like rxn
94
what is cipro for in IBD
Effective in resistant disease when used in combination with standard tx
95
when do we use metro and cipro in IBD?
Improve and can promote closure of fistulas
| Tend to recur once drugs stopped
96
what opiates are used in IBD? - diarrhea
Diphenoxylate/atropine, codeine, tincture of opium, paregoric, loperamide
