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