Module 4.1.2 (Management of IBD) Flashcards
What is IBD?
- Inflammation of the intestine
Include
- Crohn’s disease
- Ulcerative colitis
> chronic, relapsing, remitting immune-mediated inflammation at various sites of the gastrointestinal tract
What are the signs and symptoms of IBD?
- abdominal cramps and pain
- frequent, watery diarrhea (may be bloody)
- severe urgency to have a bowel movement
- fever during active stages of the disease
- loss of appetite and weight loss
- tiredness and fatigue
- anaemia (due to blood loss)
What is the difference between UC and CD
Chrons Disease
- Chronic inflammation that may affect any part of the GI tract from mouth to anus
- Inflammation may extend to of all layers of the GI mucosa
- The pattern of inflammation is segmental rather than continuous (skip lesions)
Ulcerative colitis
- Inflammation only affects the superficial mucosa
- Mainly affects the rectum and distal colon but may extend to involve the entire colonic mucosa
- Inflammation tend to be continuous rather than patchy
For CD, define the following terms;
A) Ileitis
B) ileo-colitis
C) Colitis
A)
- (inflammation of the ileum, the final part of the small intestine)
B)
- (inflammation of the last part of the small intestine (ileum) and the first part of the colon)
C)
- (inflammation in all of the colon)
Diarrhoea, abdominal pain and malnutrition shared among the three
What is the difference between mild and severe UC
Mild
- Distal colon & rectum. Progression to the remainder of colon in 15% of patients
- Diarrhoea: Intermittent, 3- 5/day often without cramping pain
- Fever: Absent
- Anorexia and weight loss: absent
- Systemic sx: absent
Severe
- Usually involves the whole colon (pan colitis)
- Diarrhoea: Profuse or constant liquid stools with blood
- Fever: Present 380C to 400C
- Anorexia and weight loss: severe and persistent
- Systemic sx: extreme fatigue, weaskness, prostration
What are the aims of drug treatment in UC and CD?
UC
Inducing remission
- Controls symptoms during active disease
- Remission achieved within 7-14 days if patient responds to treatment
Maintaining remission
- Prevents symptoms from coming back when in remission
What type of drug treatment to use for rectum and distal colon?
Topical preparations
What are the SIX medication treatment options in IBD?
- Corticosteroids (topical, oral, IV)
- 5-Aminosalicylates (topical, oral)
- Immunosuppressants (oral, IV)
- TNF-alpha antagonists (SC, IV)
- Vedolizumab (IV)
- Ustekinumab (SC)
For corticosteroids;
A) why are they used?
B) what are examples? Include forms.
C) What to use for distal colonic inflammation?
D) What to use for severe cases?
E) What are some adverse effects?
F) What happens if stopped rapidly?
put how to taper doses on word doucment notes
A)
- Inducing remission in acute disease
B)
- Hydrocortisone (rectal foam), prednisolone (oral, supp, enema), budesonide (oral, rectal foam)
C)
Topical formulation for distal colonic inflammation
- Suppositories, foam, enema
D)
- IV methylprednisolone for severe cases for 3-5 days then switch to oral formulation
> 70% of patients improve after 2-4 weeks of 40mg of oral prednisolone/day
E)
- Weight gain
- Infection
- Hypertension
- Dyspepsia
- Diabetes
From porlonged use e.g. more than 12 weeks
F)
- Rapid reduction associated with early relapse and acute adrenal crisis
For 5-Aminosalicylates (5-ASA);
A) What is the main role?
B) What are the types of drugs? Which drug to use first
C) What types to use for rectum and distal colon
D) What combination is effective
E) What to monitor for?
A)
- Inducing remission in UC and CD
- Maintenance of remission in UC (controversial role in CD)
B)
- Include balsalazide (oral), mesalazine (oral, supp, enema, rectal foam), olsalazine (oral), sulfasalazine (oral)
- sulfasalazine (oral) –> use first
C)
- Supp, enema and rectal foam for disease confined to rectum and distal colon
D)
- Combination of rectal + oral 5-ASA more effective than either alone
E)
- Monitor LFTs, FBP, renal function tests
For Immunosuppressants;
A) What are the types of drugs used?
B) Why are they used?
C) What drugs to use if first-line treatment is not tolerated?
D) What is the role of IV cyclosporin?
E) What to monitor?
F) What happens when there is low enzyme or high enzyme activity of TPMT in mercaptopurine metabolism?
A)
- Azathioprine, mercaptopurine, IV ciclosporin, methotrexate
B)
- Main role of Azt & Mercaptopurine: Maintenance of remission in patient requiring continuous steroid for control
C)
- MTX (with folic acid) reserved for patient who could not tolerate above drugs
D)
- Inducing remission in severe UC if sx fail to improve after 3-5 days of IV corticosteroid (methylprednisolone)
E)
- Monitor FBC and LFT and renal function (with ciclosporin)
F)
- Low enzyme activity leads to increased risk of myelosuppression
- High enzyme activity lead to reduced efficacy
For TNF-alpha antagonists;
A) What is its main role?
B) Examples of drugs
C) What precautions are they?
D) Why is a review done every 3 to 6 months?
A)
To induce remission and maintain remission In severe UC & CD if sx refractory to standard therapy
- Can be used as first line tx if disease is severe and extensive
B)
- Adalimumab (SC), infliximab (IV)
C)
- Infection history
- TB and hepatitis screening
- Vaccination status
D)
- To assess the efficacy of therapy and any adverse effects
For Vedolizumab and Ustekinumab;
A) What is it’s main role?
B) what is Vedolizumab specifically used for?
C) What is Ustekinumab specifically used for?
A)
- To induce remission and maintain remission in severe UC & CD if sx refractory to TNF-alpha antagonist
B)
- For moderate to severe CD and UC
- Not as effective as anti-TNF agents for patient with extra intestinal manifestations
C)
- New drug
- For moderate to severe CD only
Acute severe ulcerative colitis is defined by the presence of 6 or more bloody stools per day, plus at least one of the following. What are some of the other signs?
symptoms are similar to CD
- temperature more than 37.8ºC
- heart rate more than 90 beats/minute
- haemoglobin less than 105 g/L
- erythrocyte sedimentation rate more than 30 mm/hour
What are some of the risk factors for a severe acute flare of UC?
- Missing IBD medications or taking the incorrect dose
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Antibiotics
- Smoking (Crohn’s disease)
- Stress
- Food
How to treat severe acute flare of UC? What to do when symptoms improve?
Methylprednisolone IV
- If sx improve, switch to oral prednisolone and start therapy to induce remission
>If inadequate response, ciclosporin 2 mg/kg intravenously, daily as a 24-hour continuous infusion
> OR infliximab 5 mg/kg by intravenous infusion over 2 hours, at week 0, 2 and 6.
How to treat distal colitis (end of rectum) UC? to induce remission
- Rectal 5-ASA + Oral 5-ASA
–>
- If not effective, use oral 5-ASA with rectal corticosteroid (continue until sx resolves then taper)
–>
- If not effective, add on oral prednisolone (40-50 mg daily until sx resolves then taper over 8-12 weeks)
How to treat extensive UC (ie colitis proximal to the splenic flexure)?to induce remission
- Oral 5-ASA
–>
- If not effective, add on oral prednisolone (40- 50 mg daily until sx resolves then taper over 8-12 weeks)
–>
- If not effective, add on TNF-alpha antagonist/ vedolizumab
Once acute episodes of UC are under control –> what is used for the following maintenance control?
A) First line?
B) If severe initial disease OR frequent relapse?
C) Chronically active disease that is refractory to the above therapy?
A)
- Oral 5 ASA daily +/- rectal ASA (2-3 x weekly)
B)
- As above + Azathioprine (daily) OR mercaptopurine (daily) OR methotrexate + folic acid (weekly)
C)
- TNF-alpha antagonist OR vedolizumab
What is used for the symptomatic management for the treatment of UC?
Anti-diarrhoeal
- Loperamide only in mild disease
- DO NOT USE IN SEVERE DISEASE –> causes toxic megacolon (faecal matter backs up, put pressure on colon, causes damage and ruptures colon)
> avoid antispasmodic (hyoscine butylbromide), anticholinergics, and opioid analgesics in severe disease
> reducing intake of insoluble fibre may provide symptomatic relief of diarrhoea during acute flare for some patients
What is the most important factor in maintaining remission in CD?
Smoking cessation is the most important factor in maintaining remission
Treatment of CD is similar to the treatment of UC with what difference?
5-aminosalicylates oral and rectal therapy have a limited role in Crohn’s disease
What does the following severity classification mean for CD
A) S0
B) S1
C) S2
D) S3
A)
- Clinical remission
B)
- Mild (<4 bowel actions/day, no sign of systemic toxicity)
C)
- Moderate
D)
- Severe (>6 bowel actions/day with sign(s) of systemic toxicity)
What treatment to use for mild to moderate CD? Also what to use for ileocaecal disease? to induce remission
Oral prednisolone 40-50mg daily (Taper after clinical response)
- For ileocaecal disease: Oral budesonide 9 mg daily for 8 weeks then gradually taper
