Inflammatory bowel disease therapy

Question 1

What are the aims of IBD therapy?

Answer 1

Control inflammation and heal mucosa
Restore normal bowel habit
Improve quality of life
Balance the effects of the disease with the side effects of the treatment
Avoid long-term complications
Be a good advocate for the patient

Question 2

What are the three therapeutic strategies?

Answer 2

Lifestyle advice
Drugs
Surgery

Question 3

What lifestyle advice can be given in the treatment of IBD?

Answer 3

Smoking aggravates Crohn’s.

Diet is not implicated in pathogenesis but can influence symptoms

Question 4

What drugs are used in the treatment of ulcerative colitis?

Answer 4

5ASA (mesalazine)
Steroids
Immunosuppressants
Anti-TNF therapy- not allowed to use these for UC in Britain
Step up treatment depening on severity of disease

Question 5

What drugs are used in the treatment of Crohn’s disease?

Answer 5

Steroids
Immunosuppressnats
Anti-TNF therapy
Step up treatment depending on severity of disease

Question 6

Why is mesalazine not used to treat Crohn’s disease?

Answer 6

It is not potent enough

Question 7

What is the mechanism of action of 5ASA drugs?

Answer 7

It has a topical effect
It dissolves as it travels through the intestines and coats the lining of the colon
The medicine only releases the active ingredient when it hits the colon.
It has anti-inflammatory properties
It reduces the risk of colon cancer

Question 8

What are the side effects of 5ASA drugs?

Answer 8

Diarrhoea

Idiosyncratic nephritis

Question 9

What forms of administration do 5ASA drugs come in?

Answer 9

Oral:
pro drugs
pH dependent release
delayed release

Topical:
Suppositories
Enemas

Question 10

Name some 5ASA conjugates

Answer 10

Sulphasalazine
Balsalazide
Mezavant
Mesalazine
Asacol (pH release)
Pentasa (delayed release)

Question 11

How safe is it to give big 5ASA drug doses?

Answer 11

Quite safe to give big doses

Want to avoid moving up to steroids as the side effects are greater

Question 12

What properties do corticosteroids have?

Answer 12

Systemic anti-inflammatory properties

Question 13

When and for how long should steroids be given?

Answer 13

To induce remission
For a short course
High dose initially, reducing over 6-8 weeks

Question 14

Name two corticosteroids

Answer 14

Prednisolone

Beclametasone

Question 15

What are side effects of steroids?

Answer 15

Musculoskeletal:
Avascular necrosis
Osteoporosis

Gastrointestinal

Cutaneous:
Acne
Thinning of skin
Metabolic:
Weight gain
Diabetes
hypertension

Neuropsychiatric

Cataracts

Growth failure

Question 16

What should be co-prescribed along with steroids?

Answer 16

Vitamin D and calcium

Question 17

When should immunosuppression treatment be used?

Answer 17

When more potent suppression of the inflammation is required.
If a patient is requiring repeated steroid treatments, may step up to immunosuppression to spare the use of steroids.
All Crohn’s patients should be on immunosuppression from the beginning, as maintenance therapy.

Question 18

Give examples of immunosuppresive drugs

Answer 18

Azathioprine/mercaptopurine

methotrexate

Question 19

What test should routinely be done before starting a patient on azathioprine?

Answer 19

A gene test.
The enzyme important in the metabolism of this drug is lacking in 0.3% of patients. If those patients kept taking the drug, they would have bone marrow problems within a week.

Question 20

Which enzyme’s activity contributes to the toxicity of azathioprine?

Answer 20

TPMT

Question 21

What should not be co-prescribed with azathioprine?

Answer 21

Allopurinol (xanthine oxidase inhibitor)

Question 22

What are side effects of azathioprine?

Answer 22

pancreatitis
leucopaenia
Hepatitis
Small risk of lymphoma and skin cancer

Question 23

How does anti-TNF therapy work?

Answer 23

The drugs attach to tumour necrosis factor alpha (a pro-inflammatory cytokine) and disable it.

Question 24

What are the anti-TNF drugs?

Answer 24

They are antibodies to TNF
infliximab- part human part mouse. Give IV and must be given in hospital in case of anaphylaxis
Adalimumab- completely human. Give subcutaenously and can be given at home.

Question 25

How long does it takae anti-TNF drugs to work?

Answer 25

They work within 24 hours

Question 26

As well as disabling TNF alpha, what else to anti-TNF drugs to?

Answer 26

They promote apoptosis of activated T-lymphocytes

Question 27

How long do the effects of anti-TNF drugs last for?

Answer 27

Several weeks. | The patients have to get regular therapy.

Question 28

Which condition is anti-TNF therapy used to treat?

Answer 28

Crohn's disease

Question 29

What are patients tested for before being started on anti-TNF therapy?

Answer 29

TB

Question 30

When should anti-TNF therapy be used?

Answer 30

as part of long term strategy, including immune suppression, surgery, supportive therapy refractory / fistulising disease exclude current infection / TB

Question 31

When is surgery used in the treatment of IBD?

Answer 31

``` Emergency Failure to respond to medical therapy, small bowel obstruction, abscess, fistulae Elective Failure to respond to medical therapy Dysplasia of colon mucosa ```

Question 32

Is surgery in Crohn's curative?

Answer 32

No.

Question 33

Why should the amount of bowel removed in Crohn's disease be minimised?

Answer 33

Repeated resection of small intestine can result in ‘short gut syndrome’ and requirement of lifelong total parenteral nutrition (reduced life expectancy)

Question 34

What is the surgical treatment for recurrent perianal abscesses? Why is it damaging to have repeated abscess formation?

Answer 34

The insertion of a seton. It is passed into the cavity and back out the other side, and acts like a wick, drawing fluid out. Repeated abscess formation would lead to damage of external sphincter and incontinence.

Question 35

What is the surgery for ulcerative colitis? | Is it curative or not?

Answer 35

``` It is curative. The options are Permanent ileostomy OR Restorative proctocoloectomy and pouch ```

Question 36

What sort of pouch can be formed in a restorative proctocoleoctomy?

Answer 36

A J pouch. | This acts like a rectum to hold "faeces"- although it is not true faeces, and everything that comes out will be liquid.

Question 37

How often to patients with J pouches go to the toilet? | What complications are there?

Answer 37

They go 4/5 times a day and in the night Incontinence is common There can be pouch failure after a number of years and inflammation can set in

Question 38

What is the IBD therapy pyramid?

Answer 38

``` Smoking cessation 5-ASA (UC) Steroid if required Immunosuppression Anti-TNF therapy Surgery may be the best treatment in some ```