IBD

Question 1

IBD S/Sx

Answer 1

*Blood in stool
Diarrhea
Abdominal pain/cramps
Weight loss
Fatigue
Change in QoL

Question 2

IBD Diagnosis

Answer 2

*Monitor Labs (ESR, CRP)
*Stool Studies (Lactoferrin, Calprotectin, Leukocytes)
Monitor symptoms
Colonoscopy
CT/MRIs

Question 3

Types of UC

Answer 3

a. Proctitis: Only rectum

b. Left sided/Distal Colitis: involvement up to splenic flexure

c. Extensive/Pancolitis: involves entire large intestine

Question 4

UC characteristics

Answer 4

• Confined to rectum + colon
• Continuous inflammation
• Progressive disease
• NO perianal involvement

Question 5

UC complications

Answer 5

• Toxic megacolon
• Colon cancer

Question 6

Chron’s characteristics

Answer 6

• Mouth to anus (entire GI tract)
• Most common in terminal ileum
• deep, patchy crypts
• “cobblestone appearance”
• Inc perianal involvement

Question 7

Chron’s complications

Answer 7

• Malnutrition/vitamin deficiency (SI involved)
• Strictures
• Fistulas/fissures (perianal involvement)

Question 8

5-aminosalicylates - Drugs

Answer 8

Sulfasalazine
*Mesalamine
Olsalazine
Basalazide

Question 9

Mesalamine preps

Answer 9

• Rowasa: enema, delivers to the rectum and distal colon
• Canasa: suppository, delivers to rectum ONLY
• Pentasa: oral, delivers 5-ASA from rectum to jejunum (largest range of any rx)

Question 10

Which disease are 5-ASA preferred?

Answer 10

UC

Question 11

Immunomodulators - Drugs

Answer 11

*Azathioprine
6 - Mercaptopurine
Methotrexate
Cyclosporine

Question 12

Benefits of combining Azathioprine with steroids/biologics?

Answer 12

a. Delayed effect (~3 months)

b. Steroid sparing (avoids long-term steroid therapy)

c. Inc efficacy of biologics due to dec antibody formation

Question 13

Monitoring parameters on Azathioprine

Answer 13

a. CBC every 3 months

b. LFT/pancreatic enzymes

Question 14

Azathioprine BBW

Answer 14

Lymphoma (inc. risk when combo with biologics)

Question 15

Antibiotics - Drugs

Answer 15

Metronidazole
Ciprofloxacin
3rd gen cephalosporins

Question 16

Which disease are ABX more commonly used?

Answer 16

Chron’s: perianal involvement (fistula/fissures)
- used short term to aid in closure
- cover gram(-) / anaerobes

Question 17

Corticosteroids - Drugs

Answer 17

Prednisone
Methylprednisolone
Hydrocortisone
Budesonide

Question 18

Budesonide formulations

Answer 18

a. Entocort: Chron’s (reaches terminal ileum)

b. Uceris: UC (only colon)

Question 19

Benefits of Budesonide in IBD

Answer 19

• 15x potency vs Prednisone
• Poor systemic absorption = decreased ADEs
• do NOT combo with other steroids
• 8 week course of therapy

Question 20

Biologics - Types

Answer 20

Anti-TNFs
Selective adhesion molecule (integrin) inhibitor
IL inhibitors

Question 21

Anti-TNF - Drugs

Answer 21

Infliximab (IV)
Adalimumab (SQ)
Certolizumab (SQ)
Golimumab (SQ)

Question 22

Response rate of Anti-TNFs in IBD patients?

Answer 22

~40%
- Infliximab #1 efficacy
- Adalimumab most convenient (monthly SQ inj.)

Question 23

Anti-TNF BBWs

Answer 23

1.) Infections (TB, invasive fungal, bacterial, viral, opportunistic)
- require PPD, CXR, HBV/HCV/HIV testing

2.) Malignancy (lymphoma, inc. when combo with AZA)

Question 24

Selective adhesion molecule (integrin) inhibitor - Drugs

Answer 24

Natalizumab (IV)
Vedolizumab (IV)

Question 25

Which integrin inhibitor is preferred?

Answer 25

Vedolizumab (a4b7) - only targets T-cells in GI tract

Question 26

Natalizumab BBW

Answer 26

PML (CNS infection)

Question 27

IL Inhibitors - Drugs

Answer 27

IL-12, 23: Ustekinumab (IV, then SQ) IL-23: Risankizumab (IV, then SQ)

Question 28

NOT BIOLOGICS, but act like it - Types

Answer 28

JAK inhibitors Sphingosine 1-Phosphate (S1P) Receptor Modulator

Question 29

JAK inhibitors BBWs

Answer 29

1. Cancer 2. MACE 3. Thrombosis 4. Infections 5. Death

Question 30

When does FDA approve use of JAK inhibitors in IBD patients?

Answer 30

Patients who have failed 1 or more Anti-TNFs

Question 31

General Biologics ADEs

Answer 31

IV: infusion reactions a.) Acute: HA, fever, pruritis, nausea - Premedicate with APAP, Benadryl, IV Steroids b.) Chronic: flu-like symptoms - Premedicate with APAP, short-term steroids SQ: injection site reactions

Question 32

Mild/Mod Active Crohn’s Diagnosis

Answer 32

- PO without fever, abdomen pain, intestine obstruct - Weight loss < 10%

Question 33

Mild/Mod Active Crohn's Treatment

Answer 33

PO Budesonide (Entocort) x8 weeks

Question 34

Mod/Severe Active Crohn's Diagnosis

Answer 34

- Fever >38 C - Weight loss > 10% - Abdomen pain - N/V - Significant anemia - Failed Mild therapy

Question 35

Mod/Severe Active Crohn's Treatment

Answer 35

a. PO Prednisone 40-60 mg b. Anti-TNF (Inflix/Adalim) +/- AZA (for either)

Question 36

Severe/Fulminant Crohn's Diagnosis

Answer 36

- High fever >39 C - N/V with obstruction - Cachexia (muscle wasting) - Abscess - Persistent symptoms despite systemic steroid/biologic

Question 37

Severe/Fulminant Chron's Treatment

Answer 37

a. IV MEPN/Hydrocortisone b. IV Infliximab (after 6 weeks steroid) c. *Surgery

Question 38

Maintenance Therapy for Crohn's (Remission)

Answer 38

a. AZA if steroid induced remission b. Biologic +/- AZA if biologic induced remission

Question 39

Perianal disease treatment

Answer 39

*ABX Consider: - Infliximab for closure - Surgery if needed

Question 40

Mild Active UC Diagnosis

Answer 40

- <4 stools - Intermittent blood - Occasional urgency - Normal Hgb/ESR - Elevated CRP/FC

Question 41

Mild Active UC Treatment for Distal/Left Sided

Answer 41

a. Topical 5-ASA b. Oral 5-ASA *If 5-ASA failure: a. PO Budesonide (Uceris) x8 weeks

Question 42

Mild Active UC Treatment for Extensive Colitis

Answer 42

PO 5-ASA +/- Budesonide

Question 43

Mod/Severe Active UC Diagnosis

Answer 43

- >6 stools - Frequent blood - Often urgency - <75% normal Hgb - Elevated ESR/CRP/FC

Question 44

Mod/Severe Active UC Treatment

Answer 44

a. PO Budesonide x8 weeks b. Prednisone 40-60mg c. Biologic +/- AZA (for all)

Question 45

Fulminant Active UC Diagnosis

Answer 45

- >10 stools - Continuous Blood - Continuous Urgency - Transfusion req (Hgb<8) - Elevated ESR/CRP/FC

Question 46

Fulminant Active UC Treatment

Answer 46

a. IV MEPN/Hydrocortisone b. IV Infliximab c. IV Cyclosporine *Surgery (colectomy) will cure UC

Question 47

Maintenance Therapy for Mild UC (Remission)

Answer 47

Topical or Oral 5-ASA

Question 48

Maintenance Therapy for Mod-Severe-Fulminant UC (Remission)

Answer 48

a. AZA if steroid induced remission b. Biologic +/- AZA if biologic induced remission c. AZA or Vedolizumab if Cyclosporine induced remission