Chapter 74: Inflammatory Bowel Disease
_____ is the class of medications that have a topical anti-inflammatory effect in the GI tract.
Aminosalicylates
What can be used as maintenance therapy for moderate-severe Crohn's disease?
Anti-TNF agents (Humira, Remicade, Cimzia) Thiopurine Methotrexate IL receptor antagonist (Stelara)
Brand name of mesalamine ER capsules?
Apriso Delzicol Pentasa
Which medications used in IBD would patients see a ghost tablet?
Asacol HD Delzicol
Brand name of sulfasalazine tablets? ER tablets?
Azulfidine Azulfidine EN-tab
What is the classic symptoms of IBD?
Blood diarrhea
Brand name of mesalamine suppository?
Canasa
What are the major types of IBD?
Crohn's Disease Ulcerative colitis
Brand name of budesonide?
Entocort EC Uceris
What are foods that can trigger IBD?
Fatty foods Gas producing foods (lentils, beans, legumes, cabbage, broccoli, onions)
______ is more likely with sulfasalazine than mesalamine.
Hypersensitivity reactions
Contraindications to mesalamine?
Hypersensitivity to salicylates or aminosalicylates
What is most commonly affected in Crohn's?
Ileum Colon
For patients with moderate-severe UC the extends beyond the colon and rectum, _______ can be used.
Immunosuppressants
Side effects of Tysabri?
Infusion reactions Headache Fatigue Arthralgia Nausea Rash Depression Gastroenteritis Abdominal/back pain
UC is classified how?
Mild Moderate Severe Fulminant
Methotrexate is dosed ______ for moderate-severe Crohn's disease.
Once weekly IM or SC
What can be used as maintenance therapy for mild Crohn's disease of the ileum and/or right colon?
Oral budesonide for ≤ 3 months then d/c treatment or swap to thiopurine or methotrexate
Inflammation limited to the rectum is called ______.
Proctitis
Boxed warning for Tysabri?
Progressive multifocal leukoencephalopathy (PML) Only available through the REMS TOUCH prescribing program
Contraindications for sulfasalazine?
Salicylate allergy Sulfa allergy Obstruction (GI or urinary) Porphyria
Budeosonide is a major substrate of ______.
3A4
Side effects of mesalamine?
Abdominal pain Nausea Headache Flatulence Eructation Nasopharyngitis
______ UC disease is characterized by >/= 6 bloody stools per day with evidence of toxicity.
Severe
_____ supplements can help prevent deficiencies related to malabsorption.
Vitamin
Canasa suppository should be used at bedtime and be left in the rectum for at least _____ (preferably overnight).
1-3 hours
Tysabri should be discontinued if no response by ______ weeks, and Entyvio should be discontinued if no response by ____ weeks.
12, 14
Each container of hydrocortisone (Cortifoam) or budesonide (Uceris) rectal foam contains ____ doses of foam.
14
Separate administration of budesonide and antacids by ______.
2 hours
If steroids are used longer than _____, they must be tapers to avoid withdrawal syndromes.
2 weeks
What are the options for induction of remission in UC?
5-ASA +/- steroids or thiopurine Anti-TNF +/- thiopurine IV cyclosporine Tofacitinib
Thiopurines require an adjustment if CrCl < ______mL/min.
50
Doses of sulfasalazine should be taken at ≤ ____ intervals.
8 hour
Systemic steroids are not recommended for maintenance of remission and will usually be tapered over _____ once remission is achieved.
8-12
Warnings associated with aminosalicylates?
Acute intolerance syndrome Caution in patients with renal or hepatic impairment Delayed gastric retention Hypersensitivity reactions Increased risk of blood dyscarias in patients > 65
Long term side effects of steroids?
Adrenal suppression/Cushing's syndrome Immunosuppression/impaired wound healing Increased BP and BG Cataracts Osteoporosis
What approach with steroids can be used to decrease adrenal suppression and other adverse effects?
Alternate day therapy (ADT)
In UC, ______ are used for maintenance therapy in most patients with distal UC or mild extensive disease.
Aminosalicylates
_____ are monoclonal antibodies that bind to human TNF-alfa preventing production of proinflammatory cytokines.
Anti-TNF agents
What can be used as maintenance therapy for moderate-severe UC?
Anti-TNF agents (Humira, Remicade, Simponi) Thiopurine Cyclosporine Janus kinase inhibitor (Xeljanz)
Some patients may choose to use ____ or ____ to help with symptoms but these should be used cautiously and under supervision as they need to be avoided in select patients with IBD.
Antidiarrheals Antispasmodics
Brand name of mesalamine ER tablet?
Asacol HD Lialda
What are the thiopurines?
Azathioprine Mercaptopurine
Staining of the teeth or tongue can occur when _____ is opened and sprinkled on applesauce.
Balsalazide
If long-term use of steroids is required, ______ should be assessed.
Bone density
______ undergoes extensive first-pass metabolism so there is decreased systemic exposure than other oral steroids.
Budesonide
If long-term use of steroids is requires, optimize ____ and _____ intake and consider ______ if needed.
Calcium Vit D Bisphosphonates
Symptoms of Crohn's include what?
Chronic diarrhea Abdominal pain Weight loss
Usually a _____ is needed to make the diagnosis of IBD.
Colonoscopy with tissue biopsy
____ has a continuous pattern while _____ has a continuous pattern of ulcers/inflammation.
Crohn's Ulcerative Colitis
______ is characterized by deep transmural (through the bowel wall) inflammation that can affect any part of the GI tract.
Crohn's disease (CD)
_______ is an immunosuppressive drug recommended for severe UC.
Cyclosporine
When UC is limited to the descending colon and rectum it is called _____ disease.
Distal
Rectal steroids are used in patients with what?
Distal disease/proctitis in UC
______ is the brand of budesonide used only for Crohn's and _______ is the brand of budesonide used only for UC.
Entocort EC Uceris
All immunizations must be up to date before starting ______ and patients should not receive live vaccines during treatment unless benefit outweighs the risk.
Entyvio
Brand name of vedolizumab?
Entyvio
Put the parts of the GI tract in order that food would pass through them: rectum, esophagus, small intestine, stomach, large intestine.
Esophagus Stomach Small intestine Large intestine Rectum
T/F: Tysabri and Entyvio can be used with other immunosuppressants.
False (cannot)
T/F: Mercaptopurine should be taken with meals.
False (empty stomach)
T/F: Eating larger, less frequent meals that are low in diary and fat can be helpful to reduce flares of IBD.
False (smaller, more frequent)
IBD is a chronic intermittent disease which means symptoms can be mild to severe during _____ and minimal to absent during _____.
Flares (exacerbations) Periods of remission
_____ UC disease is characterized by > 10 stools per day and severe symptoms.
Fulminant
_____ is the formulation of balsalazide that is approved in males ONLY.
Giazo
Brand name of balsalazide?
Giazo (tablet) Colazal (capsule)
Side effects of Entyvio?
Headache Nasopharyngitis Arthralgia Antibody development
Warnings for thiopurines?
Hematologic toxicities Patients with a genetic deficiency of thiopurine methyltransferase are at increased risk of myelosuppression Serious infections Heptatoxicity
Warnings associated with Tysabri?
Herpes encephalitis and meningitis Hepatotoxicity Hypersensitivity Immunosuppression/infections
What are the rectal steroids?
Hydrocortisone Budesonide rectal foam
Short-term side effects of steroids?
Increased appetite/weight gain Fluid retention Emotional instability Insomnia GI upset Higher doses can cause increased BP and BG
Boxed warning for azothiopurine?
Increased risk of malignancy in patients with IBD Risk for hematologic toxicities Mutagenic potential
Treatments for IBD are used for ____ of remission and/or ______ of remission.
Induction Maintenance
Unlike IBD, IBS does not cause ______ and is not as serious of a condition.
Inflammation
____ is a group of inflammatory conditions of the colon and small intestine.
Inflammatory bowel disease (IBD)
Warnings associated with Entyvio?
Infusion reactions Hypersensitivity reactions Infections Liver injury PML
What can be used as maintenance therapy for refractory or steroid dependent Crohn's disease?
Integrin receptor antagonists
_______ is the class of medications that are monoclonal antibodies that bind to subunits of integrin molecules, blocking the ability of integrin to interact with adhesion molecules and preventing inflammatory cells from migrating into GI tissue.
Integrin receptor antagonists
_____ are used in patients with IBD that is refractory to other cases or those that are steroid dependent.
Integrin-receptor antagonists
IBD can be mistaken for _____ as they have similar symptoms.
Irritable bowel syndrome (IBS)
Monitor for thiopurines?
LFTs CBC (weekly for 1st month) Renal function S/Sx of malignancy
Avoid _____ use of steroids for IBD.
Long-term
What is the primary aminosalicylate used in the US?
Mesalamine
What can be used as maintenance therapy for mild UC?
Mesalamine rectal and/or oral
_____ is an immunosuppressant drug with anti-inflammatory properties.
Methotrexate
_____ UC disease is characterized by > 4 stools per day with minimal signs of toxicity.
Moderate
Side effects of thiopurines?
N/V/D Rash Increased LFTs
_____ is an injection and is approved for Crohn's disease and MS.
Natalizumab
What are the integrin receptor antagonists?
Natalizumab Vedolizumab
____use has been shown to worsen Crohn's but protective in UC.
Nicotine
Short courses of ____ are commonly used to treat acute exacerbations in both UC and Crohn's.
Oral or IV steroids
Canasa and Rowasa should preferably be left in how long?
Overnight
What are some natural products that might be useful in IBD?
Peppermint Chamomile Tea Indian frankincense
What oral steroids are used in IBD?
Prednisone Budesonide
____ are natural products that can reduce abdominal pain, bloating, urgency, constipation or distract in some patients.
Probiotics
______ form of mesalamine is more effective than oral mesalamine.
Rectal
Brand name of mesalamine enema?
Rowasa
For best results when using ______ and ______, patients should empty the bowel immediately before use.
Rowasa enema Canasa suppository
Contraindication for olsalazine?
Salicylate allergy
Contraindications for balsalazide?
Salicylate allergy
What are options for induction of remission in Crohn's?
Steroids +/- thiopurine or methotrexate Anti-TNF +/- thiopurine Interleukin receptor antagonist
Aminosalicylates inhibit _____ so caution when using in combination with thiopurines.
TMPT
Consider testing for ____ before starting azothiopurine.
Thiopurine methyltransferase deficiency (TMPT deficiency)
_____ is the class of immunosuppressive drugs, sometimes referred to as the immunomodulators.
Thiopurines
____ is an oral tablet that inhibits janus kinase enzymes which are involved in stimulating immune cell function and is approved to treat moderate-severe UC.
Tofacitinib (Xeljanz)
Distal UC can be treated with what?
Topical Rectal treatment
Patients with fulminant disease are at risk to progressing to what?
Toxic megacolon Bowel perforation
T/F: Budesonide should be swallowed whole - not broken, crushed, or chewed.
True
T/F: Mesalamine is better tolerated than the rest of the aminosalicylates.
True
T/F: Rowasa and Canasa can stain surfaces, so take caution when administering.
True
T/F: Thiopurines can be used in induction and maintenance therapy in IBD.
True
Brand name of natalizumab?
Tysabri
______ is only available through the REMS TOUCH prescribing program.
Tysabri
Aminosalicylates are indicated for treatment of ____.
UC
Rectal steroids are indicated for ______ only.
UC
______ is characterized by mucosal inflammation confined to the rectum and colon with superficial ulcerations.
Ulcerative Colitis (UC)
_____ is a monoclonal antibody that binds to and interferes with IL-12 and IL-23 and is used for patients who have not yet failed or are intolerant to anti-TNF treatment.
Ustekinumab (Stelara)
_______ is an injection approved for Crohn's disease and UC.
Vedolizumab
What can be used as maintenance therapy for refractory or steroid dependent UC?
Vedolizumab (Integrin receptor antagonist)
For mild Crohn's disease that is limited to the ileum and proximal colon, ______ is preferred.
budesonide
If the Rowasa has a _____ color, it should not be used and thrown away.
dark brown
