Week 11: Ulcerative Colitis Flashcards by C L

Explain the main features of Crohn’s Disease. (2)

Involves distal ileum, proximal colon, can affect entire digestive tract.

Inflammation can go through entire bowel wall thickness.

‘Cobblestoning’ structure

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Explain the main features of Ulcerative Colitis. (3)

Affects only the colon
Diffuse inflammation
Affects the colonic mucosa.

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What are the general s/s of CD + UC? (7)

Ab. pain/cramping
Diarrhoea (+/- blood/mucus)
Urgency
Fever
Fatigue
Weight/Appetite loss
Mouth Sores

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Give e.g. of extra-intestinal manifestations that can present in UC + CD. (6)

Skin, eyes, joints + liver inflammation:
- Ankylosing spondilitis (spine/hip joint)
- Arthritis
- Erythema nodosum (flushing skin/shin tenderness)
- Uveitis (eye inflammation)
- Aphthous ulcers (painful open ulcers)

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What are the potential complications of both CD + UC? (7)

Increased risk of colon cancer.
Malnutrition
Anaemia
Medication risks (cancers, HPT, OP)
Blood clots
Primary Sclerosing Cholangitis

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What are the potential complications of Crohn’s Disease? (3)

Bowel wall narrowing (obstruction/Fistulas)
Ulcers
Anal Fissures

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What are the potential complications of Ulcerative Colitis? (2)

Perforated Colon
Toxic Megacolon

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What are the risk factors of CD + UC? (5)

Age
Family Hx
Infection
Smoking
Medication

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What are the main causes of CD + UC? (3)

Genetics
Environment
Autoimmune

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Give e.g. of investigations taken place for diagnosing UC/CD. (6)

Examination + Hx taking
Colonoscopy/sigmoidoscopy - Biopsies
Stool Cultures
Ab. X-ray
Blood tests - anaemia/inflammation
Endoscopy

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What are the differential diagnoses of CD/UC? (8)

Colorectal Cancer
Other forms of IBD/Colitis
Infection
Diverticular disease
IBS
Appendicitis
Ectopic Pregnancy
Pelvic Inflammatory Disease

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Explain the main differences between CD + UC in terms of disease distribution, rectal involvement, type of inflammation, diarrhoea, pain
extra-intestinal symptoms and smokers. (14)

CD: Throughout GIT, Occasionally, Patchy/transmural, mild-severe, colicky can mimic appendicitis, yes, higher rates.

UC: In colon, usually, continuous/mucosal, mild-very severe, lower ab. discomfort, yes, lower rates.

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What are the treatment aims for CD/UC? (2)

Heal inflammation and reduces symptoms during flare-up.

Flare-up prevention

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Explain the Truelove + Witt’s Severity Index including the following: bowel movement per day, blood in stools, pyrexia, pulse rate > 90bpm, Anaemia (<10g/100ml), ESR. (18)

Mild: < 4, No more than small amounts of blood, no, no, no, ≤30.

Moderate: 4-6, between mild + severe, no, no, no, ≤ 30

Severe: > 6 (+ one of the features of systemic upset), visible blood, yes, yes, yes, > 30.

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Explain the inducing remission process for proctitis. (3)

Topical Aminosalicylate alone.
Consider adding oral aminosalicylate to topical agent.
Consider time-lited course of topical/oral CS.

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Explain the inducing remission process for proctosigmoiditis + left-sided. (4)

1st line: Topical aminosalicylate

High-dose of oral aminosalicylate OR

Switch to high-dose oral aminosalicylate + time-limited course of topical CS.

If unable to tolerate aminosalicylates, consider time-limited topical/oral steroid.

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Explain the inducing remission process for extensive disease. (2)

Topical aminosalicylate + high dose oral aminosalicylate.

Stop topical + give high dose oral aminosalicylate with time-limited course of oral CS.

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Provide a brief summary of inducing remission of UC in mild to moderate disease. (12)

1st line: Aminosalicylates
- Topical (proctitis, proctosigmoiditis, left-sided disease) or oral if topical is declined.
- If no remission is achieved after 4 weeks, add high dose of aminosalicylates.
- Topical + oral (extensive)

2nd line: Steroids
- Prednisolone, Budesonide (Cortiment), Beclomethsone (Clipper)
- Topical/oral
- Used if aminosalicylate aren’t tolerated.
- Or if no improvement after 4 weeks
- Or 1st line in moderate to severe disease.

3rd line:
- Immunomodulators
- Biologics
- Combination of both

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What do you need to consider when safely prescribing aminosalicylate? (13)

Ensure correct brand is Rx.

C/I = salicylate allergy

S/e:
- Headache
- Indigestion
- Nausea
- Watery Diarrhoea
- Mild allergic reactions

Rare s/e:
- Blood dyscrasias
- Renal Impairment

Monitoring:
- Renal function = initially @ 3 months and then annually.
- Counselling around blood dyscrasias.

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What is the main Rx principle for corticosteroids? (1)

Lowest possible dose is initiated = minimises s/e.

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What is the correct dosing regimen for prednisolone? (1)

30-40mg daily for 1-2 weeks then reduce by 5mg every 5-7 days until stop.

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What is the correct dosing regimen for Budesonide (Cortiment)? (2)

9mg OD (morning)
Up to 8 weeks

What is the correct dosing regimen for Beclometasone (Clipper)? (2)

5mg daily (morning)
Up to 4 weeks.

When would steroids be used as tx of IBD? (2)

Effective at inducing remission.
Unsuitable for maintenance due to s/e.

What are the early effects of using steroids? (5)

Acne Oedema Sleep/Mood disturbances Dyspepsia Impaired glucose tolerance

What are the delayed effects of corticosteroids? (5)

Cataracts Osteoporosis/Osteonecrosis Myopathy Prone to infection Moon Face

What are the glucocorticoid s/e associated with taking steroids? (5)

Diabetes Osteoporosis Muscle Wasting (Myopathy) Peptic ulceration + perforation Psychiatric reactions

What are the mineralcorticoid s/e when taking steroids? (5)

Hypertension Sodium Retention H20 retention K+ loss Ca2+ loss

What does the adrenal cortex secrete? (2)

Hydrocortisone (cortisol) = glucocorticoid activity + weak mineralcorticoid activity. Mineralcorticoid aldosterone.

Explain how adrenal suppression can occur when taking steroids. (1)

During prolonged CS tx, adrenal atrophy develops and persists for yrs after stopping.

Explain the main effect of acute withdrawal of a steroid (1)

Acute withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension/death.

What actions should be taken when adrenal suppression occurs? (3)

To compensate for a diminished adrenocorticoid response caused by prolonged corticosteroid tx, any significant intercurrent illness, trauma or surgical procedure: - Temporary increase in CS dose OR - If already stopped, a temporary reintroduction of CS tx.

What action should be taken to reduce the risk of decreased BP during anaesthesia? (1)

Anaesthetists must know whether a px is or has been taking a CS.

What should be given to patient on long-term CS? (5)

Steroid card including the warnings: - Infections - Chicken pox - Measles - Psychiatric reactions

When would consider gradual withdrawal of corticosteroids? (5)

> 40mg prednisolone (or equivalent) for > 1 week. Given repeated doses in the evening. > 3 weeks tx Received repeated courses. Taken short course within 1 year of stopping long-term therapy.

What factors can increase the risk of px developing osteoporosis in IBD? (4)

High levels of CS Low BMI Reduced physical activity Disease activity

How would you manage px with OP with IBD? (4)

Manage underlying disease, good nutrition, avoidance of steroids ASAP. Lowest effective dose / steroids for shortest time possible. AZA/6MP use at early stage Biological therapy / surgery considered if px is unable to maintain a steroid free remission.

Explain the use of bisphosphonates in OP in IBD. (3)

When on steroid for > 65 yrs. If < 65 but need steroids for > 3 months. Stopped when steroids stopped unless indicated.

Explain the use of calcium + Vit. D in OP and IBD.

Not strong evidence is based on BMD but not fractures.

What are the tx options for acute severe IBD? (8)

1st line: - IV CCS - Consider ciclosporin/biologic (infliximab) = if can't tolerate/decline or c/i = CCS 2nd line: - Add IV ciclosporin to IV CCS - No improvement after 72 hrs. - Worsening symptoms OR Biologic (Infliximab)

What else do you need to consider when inducing remission for UC? (6)

Need for surgery Supportive Tx = fluids Stop harmful drugs (NSAIDs, anticholinergics, Opioids) VTE risk assessment: - At high risk of VTE - Rx a LMWH = Tinzaparin

Explain how ciclosporin is used in practice. (2)

Used to induce/maintain remission. Brand-Rx

What are the common interactions of ciclosporin? (5)

Amiodarone Atorvastatin Carbamazepine Clarithromycin Dabigatran

Explain the monitoring process for ciclosporin. (8)

Toxicity Drug ass. mortality = 3% Check serum cholesterol prior to starting Monitor: - BP - Renal function - Liver function - Serum K+, Mg2+ - Drug levels

What is the main aim of maintaining remission? (1)

To be steroid free.

What are the drugs used for maintaining remission? (4)

Aminosalicylates Thiopurines Biologics +/- Thiopurines

Explain the treatment process of maintaining remission in mild-moderate IBD. (4)

Proctitis + Proctosigmoiditis: - Topical +/or oral aminosalicylates (daily/intermittent) Left-sided + extensive: - Low-dose oral aminosalicylate.

Explain the treatment process for maintaining remission in all extents of disease. (4)

Consider oral AZA/6-MP to maintain remission: - After ≥2 exacerbations in 12 months requiring tx with systemic CCS. OR - If remission isn't maintained by aminosalicylates. OR - After a single episode of acute severe UC. Biologics: - Px with moderate to severe disease. - Has not responded to conventional therapy, can't tolerate or it's c/i. Janus Kinase Inhibitors (JKI): - Moderate to severe disease and all other tx options can't be tolerated or failure.

Give an e.g. of a JKI. (1)

Tofactinib: - Non-biologic - Potent immunosuppressant

Explain the key points you need to cover to safely prescribe JKI. (6)

Not used with biologics/immunomodulator drugs. Increased VTE frequency: - Use with caution in px with add. risk factors for VTE. - Stop if VTE develops Not recommended for > 65 yrs. Monitor lipids 8 weeks after starting tx.

What pre-treatment screening is considered for JKI's? (2)

TB Viral Hepatitis

What is a common drug interaction with JKI? (1)

CYP3A4 - dose reduced (potent CYP3A4 inhibitors)

What the common side effects when taking JKI? (4)

Headaches HPT Diarrhoea URTI

What is the name of the new drug to help treat UC? Stating its main properties? (5)

Etrasimod (Velsipity) - Mod. to severe active UC - > 16 yrs - SIP receptor modulator - Oral prep - OD dose