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GSS > Therapeutics of UC/CD > Flashcards

Therapeutics of UC/CD Flashcards

1
Q

Management of Crohn’s: mild-moderate

A

INDUCING REMISSION
1. Prednisolone (8 weeks. PO)
2. Budenoside/5-ASA
(C/I, cannot tolerate, distal ileal/ileacecal disease)

ADD-ON THERAPY

  1. Azathioprine/mercaptopurine
  2. Methotrexate

MAINTENANCE

  1. Azathioprine/mercaptopurine
  2. Methotrexate
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2
Q

Management of Crohn’s: moderate-severe

A

INDUCING REMISSION

  1. Hydrocortisone (PO/IV)
  2. Biologics (adalimumab/vedolimumab/ustekinumab/infliximab)

ADD-ON THERAPY

  1. Azathioprine/mercaptopurine
  2. Methotrexate

MAINTENANCE

  1. Continuing biologics
  2. Azathioprine/mercaptopurine
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3
Q

Management of Crohn’s: fistulating disease

A

INDUCING REMISSION

  1. Antibiotics/drainage of abscess
  2. Biologics (infliximab/adalimumab)

ADD-ON THERAPY
1. Azathioprine/mercaptopurine

MAINTENANCE

  1. Continuing biologics
  2. Azathioprine / methotrexate
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4
Q

Management of UC: mild

A

INDUCING REMISSION

  1. 5-ASA
  2. Prednisolone/budenoside/beclomethasone

ADD-ON/MAINTENANCE

  1. 5-ASA
  2. (>2 exacerbations) Azathioprine/mercaptopurine
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5
Q

Management of UC: moderate

A

INDUCING REMISSION

  1. 5-ASA
  2. Prednisolone/budenoside/beclomethasone
  3. Tacrolimus

ADD-ON/MAINTENANCE

  1. 5-ASA
  2. Azathioprine/mercaptopurine
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6
Q

Management of UC: severe

A

INDUCING REMISSION

  1. IV Hydrocortisone
  2. IV Ciclosporin
  3. Biologics (Infliximab)
  4. Surgery

ADD-ON/MAINTENANCE

  1. Continue biologics
  2. Azathioprine/mercaptopurine
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7
Q

Benefits of Budenoside

A

Less effective and expensive
Used in disease affecting distal ileum, ileocecal, and ascending colon

Reduced s/e due to extensive first pass metabolism (less adrenal suppression)

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8
Q

5-ASA

A

5- aminoasalicylates (Others- olsalazine)

1) Sulfalazine (5-ASA + sulfapyridine)
- less commonly used now
- useful for patients with cross-overs e.g. suffer from RA/joint issues

2) Mesalazine (Coated 5-ASA designed for delivery in the colon)
- Released at pH 7
- Most commonly used

S/E
- Blood dycrasias (abnormal material found)
> brusising, bleeding, sore throat, malaise 
- Hypersensitivity
- Reduced renal function
- Hepatitis
- Headaches
- Dry Skin
- Male infertility (reversible)
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9
Q

What immunosuppressant is suitable in pregnancy?

A

Azathioprine

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10
Q

When are immunosuppressants considered?

A

> 2 exacerbations within 2 months (meaning 2+ courses of steroids)
Steroid-dependent or resistant patients

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11
Q

What are the benefits of immunosuppressants?

A 
Reduce need for steroids
Mucosal healing (reduce T cell signalling)
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12
Q

Which immunosuppressants cannot be used in Crohn’s?

A

Tacrolimus or Ciclosporin

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13
Q

Overview: Thiopurines

A

Prodrug: Azathioprine
Metabolite: Mercaptopurine
- Inhibit ribonucleotide synthesis and induce T cell apoptosis
- Onset takes 2-3 months to occur

AZ 80% metabolised into MP
Extensively metabolised to active thioguanine nucleotides (checked 4-6 weeks after initiation)

TPMT (thiopurine methyl transferase) levels monitored prior to initiation (dose dependent- intermediate/deficient in enzymes require dose changes)

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14
Q

Side effects of immunosuppressants and monitoring

A
  • Flu-Like symptoms (after 2-3 weeks; self limiting)
  • Nausea
  • Vomiting
  • Idiosyncratic Pancreatitis
  • Liver toxicity
  • Bone marrow suppression

FBC, CRP, LFT, Thioguanine nucleotides

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15
Q

Overview: Methotrexate

A

25mg OW 16/52
Then 15mg OW 40/52

Measure methotrexate polyglutamate levels for first 8 weeks until steady state metabolism

S/E

  • nausea and vomiting
  • lung and liver disease
  • bone marrow suppression
  • mouth ulcers
  • teratogenic
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16
Q

Overview: Ciclosporin

A

IV

  • Steroid-resistant patients
  • Duration 3-6 months
  • Alternative: Tacrolimus
17
Q

At what point must cover against infection be considered?

A

When on 3 immunosuppressants e.g. ciclosporin, azathioprine and steroid

Use co-trimoxazole

Risk of PCP (pneumocystis pneumonia)

18
Q

Overview: Available biological therapies

A

ALL ANTI-TNFa
Patients progressively loose response overtime due to development of antibodies (immunosuppressants used when possible)

1) Infliximab
- genetically engineered murine-human monoclonal antibody antibody
- IV infusion 0, 2, 6, 8 weekly
- Must screen for latent infections such as TB, psoriasis, dermatitis, neuropathy

2) Adalimumab
- fully humanised monoclonal antibody
- better s/e compared to infliximab
- can be administered at home weekly

3) Golimumab
- S/C injection
- 4 weekly
- weight dependent

4) Vedolizumab
- 8 weekly infusion
- Preferred in geriatrics: gut-specific
- Binds to ‘gut homing’ lymphocytes and blocks recruitment of inflammatory cells
- Reduced s/e

19
Q

Contraindications against biological therapies

A

Active infection
Moderate/severe heart failure
Hypersensitivity

20
Q

Pre-screening before biological therapies

A 
HIV
Shingles
Hepatitis B and C
Chickenpox 
Tuberculosis
Active malignancy

FBC
LFTs
CRP
Renal function

21
Q

Different antibiotics that can be used

A
  1. Metronidazole
    - 6 months after surgery
    - 3 months after anastomosis surgery
    - Active fistulating disease
    - Bacterial overgrowth
  2. Ciprofloxacin +/- Rifampicin
    - Anti-MAP therapy
    - treating bacterial overgrowth
    - long course, low dose
22
Q

Adjunctive treatments (holistic)

A

Smoking cessation
Diet (i.e. FODMAP diet)
Antimotility and antispasmodic drugs (codeine, loperamide)
Cholestyramine (diarrhoea due to bile acid malabsorption, especially after ileal resection)
Iron and vitamins
Stress management

23
Q

Indications for surgery in UC

Types

A

Unresponsive to medical therapy
UC: toxic megacolon
Colorectal Cancer

  1. Colectomy (partial/full removal)
    - maintain full anal function and consistency
  2. Ileostomy
    - permanent stoma fitted
    - can cause malabsorption problems
24
Q

Indications for surgery in CD

A
  • Unresponsive to medical therapy
  • Disease is treatable by surgery
  • Severe perianal infection, cancer, obstruction, fistulae, abscess, strictures, perforations
  • Short bowel syndrome
  • Stoma
25
Q

Limitations and risks of surgery

A
  • Pouchitis
  • Faecal incontinence
  • Prolapse
  • Anastomatic stricture/leak
26
Q

Aims of treatment

A

Aggressive treatment during flare
Inducing remission
Maintaining and symptomatic treatment in remission

27
Q

Choice of therapy depends on…

A

Severity of disease
Disease extent and location
Patient preference
Response to treatment

28
Q

Generally, what do corticosteroids do?

A

Inhibit phospholipase A2 activity and AA-PG cascade

GSS (8 decks)

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