Treatment of Inflammatory Bowel Disease Flashcards
(22 cards)
Two dermopathies associated with inflammatory bowel disease
Pyoderma gangrenosim
Pyoderma nodosum
Mouth features in IBD
Oral facial granulomatous
Steroids for flare ups
Glucocorticoids
- Iv hydrocortisone, methylprednisolone for hospital admissions
- oral prednisolone - home
Rapidly induction of remission
Slow reducing course
- prednisolone 40mg daily/1 week
- reduce by 5mg/week
Side effects of steroids
- immunosuppresion
- impaired glucose tolerance
- osteoporosis
- weight gain
- cushingoid appearances
Aminosalicylates (5-asa)
- anti-inflammatory
- ph dependent release/resin coated (Asacol)
- time controlled release (pentasa)
- Deliver by carrier therapys
Main role of aminosalicylates
- maintenance of remission in UC
- efficacy more related to complicance than delivery system
- maintenace therapy may reducer cancer risk
- little evidence to support use in crohn’s
Side affects of aminosalicylates
Sulphasalazine 10-45%
Mesalazine intolerance 15%
- renal impairement (interstial nephritis ) is rare
- diarrhoea, nausea, rarely pancreatitis, bone marrow problems
Thiopurines
Azathioprine and mercaptopurine (mercaptopurine is the active metabolite) however more expensive
-effective in active and maintenance therapy for UC and Crohns
Steroid sparing agent:
- those requiring 2+ course steroids in a year
- relapse on
Thiopurine mechanism of action
- purine anti-metabolytes
- essentially prevent T cell clonal expansion in response to antigenic stimuli
- allow T cell apoptosis
Thiopurine dosing
Dose dependent on weight
- 1.5mg/kg/day azathioprine
- 1-1.5mg/kg/day mercaptopurine
Monitoring (overly immunosuppresion)
-weeekly FBC for 8/53 then at least every 3/12
Side effects of thiopurines
- nause, vomitting
- leucopenia
- arthlagia
- pancreatitis
- hepatitis
Main enzyme for metabolising mecaptopurine
TPMT
- thipurine methytransferase
- genetically determined
- absent/low/normal activity
- predicts bone marrow suppression
- checked prior to starting
Dosing of thipurines
checked with active metabolites
6-TGN
- Active metabolite of thipurines
- measurement allows dose escalation
- also identifies non-compliance
meMP
- metabolitie associated with hepatotoxicity
- allows dose reduction to minisime risk
Give allopurinal + mecatopurine in low doses to even out levels of metabolities
Methotrexate
- anti-metabolities
- folate scavenger- need folate supplements
- 15-25mg weekly
- effective in crohns
- little evidence in UC
- widely used in inflammatory disease
- serious teratogenicity
Adverse affects of methotrexate
- highly teratogenic
- hepatotoxic -liver fibrosis
- pulmonary fibrosis
- nausea, malaise, GI upset
Biologics
Infiximab
- murine anti-TNF-alpha monoclonal antibody
- severe or fistulating corhns
- some beenefit in acute severe UC
- 2 monthly intravenous infusion
- loss of efficacy
- allergic reactions
- expensive
Adalumimab
- humanised anti-TNF alpha monoclonal antibod
- fortnightly SC injections
- less reaction
- less need for concomitant immunospurresion
- arginally less expensive
Acute severe colitis
patients who fail to respond o to optimal treatment
- IV steroids
- Liaison with colorectal surgeon
- stool frequency ?8/day/CRP >45 on day 3 predicts colectomy in 85%
Criteria for acute severe colitis
Truelove & Witts
Spilt into mild and severe
Bms/day Pr blood Temperatire Pulse Hb ESR
Acute severe collitis investifations
Daily FBC, ESR, U&Es, CRP
- stool cultures (including C.difficile)
- daily AXR
- Sigmoidoscopy
Treatment for acute severe collitis
Prophylactic LMW heparin
IV hyrdrocortisone 100mg QDS
Treat for 72 hours
- -improving then oral prednisiole-40mg
- no improvement - rescue therapy
Rescue therapy for acute severe colitis
Ciclosporin 2.g/kg/day IV
Infliximab 5mg/kg single dose
Surgery
If medical therapy doesnt work then surgery indicated
Surgery for UC and Crohns
UC
- surgery curative
- ileo-anal pouch or ileostomy
Crohns
- indicated for stricturing, perforation, fistulising disease
- sparing as will come back
- not curative
