What is Crohn’s diease?
- Can affect any part of the GIT
- Patchy, transmural (goes through the gut wall) inflammation
- Defined by location/pattern (inflammatory, fistulating, sticturing)
Can be mild to fulminant (severe(
What are the symptoms of Crohn’s disease?
- Small bowel- pain after eating, more likely to obstruct
- Large bowl- pain, diarrhoea
- Peri-anal- fistulas
- Weight loss, fever, general tiredness, diarrhoea (sometimes bloody)
- Lower right abdominal pain or central
- Tender lower abdomen mass
- Malabsorption, hypovitaminosis
- Anorexia
What is UC?
- Limited to the colon
- Diffuse mucosal inflammation
- Distal – rectum/sigmoid colon
- Extensive disease- left sided colitis or whole colon (pancolitis)
- Not associated with fistulae/fissures so no peri-anal disease
- Most are limited to left side
- Mild to fulminant (severe)
What are the symptoms of UC?
- Bloody, mucousy diarrhoea, anaemia (due to bleeding), nausea and vomiting, dehydration
- Lower abdominal cramps and pain on defaecation
What are the complications associated with IBD?
- Strictures
- Dietary restriction
- Vitamin deficiencies
- Anaemia
- Fistulae
- Dehydration
- Adverse effects on work/study
- Surgery
What is proctitis?
Inflammation of lining of rectum
How do you manage mild to moderate CD (induce remission, add on therapy and maintenance)?
Inducing remission:
- Oral prednisolone
- OR budesonide/5-ASA
Add on therapy:
- Azathioprine/mercaptopurine
- OR methotrexate if >2 exacerbations in 12 months or steroids can’t be weaned
Maintenance:
- Azathioprine/mercaptopurine
- OR methotrexate
How do you manage moderate to severe CD (induce remission, add on therapy and maintenance)?
Inducing remission:
- Glucocorticoids
- Consider biologic e.g. infliximab
Add on therapy:
- Azathioprine/mercaptopurine
- OR methotrexate
Maintenance therapy:
- Biologic e.g. infliximab
Potentially with azathioprine/mercaptopurine
Or methotrexate only
How do you manage fistulating disease CD (induce remission, add on therapy and maintenance)?
Inducing remission:
- Antibiotics and drainage
- Consider infliximab or adalimumab
Add-on therapy:
- Azathoprine/mercaptopurine
- OR methotrexate
Maintenance therapy:
Maintenance therapy:
- Biologic e.g. infliximab
Potentially with azathioprine/mercaptopurine
Or methotrexate only
How do you manage mild UC (induce remission, add on therapy and maintenance)?
Inducing remission:
- Oral 5-ASA (or topical if appropriate)
- OR topical/oral beclomethasone/budesonide/prednisolone if no improvements after 4 weeks of 5-ASA
Add on therapy/maintenance:
- Oral 5-ASA (or topical if appropriate)
AND
Azathioprine/mercaptopurine if > 2 exacerbations in 12 months needing systemic corticosteroids or if 5-ASA did not work
How do you manage moderate UC (induce remission, add on therapy and maintenance)?
Inducing remission:
- Oral 5-ASA (or topical if appropriate)
- OR topical/oral beclomethasone/budesonide/prednisolone if no improvements after 4 weeks of 5-ASA
- OR tacrolimus (immunosupressant) if no response after 2-4 weeks steroids
Add on therapy/maintenance:
- Oral 5-ASA (or topical if appropriate)
AND
Azathioprine/mercaptopurine if > 2 exacerbations in 12 months needing systemic corticosteroids or if 5-ASA did not work
How do you manage severe UC (induce remission, add on therapy and maintenance)?
Inducing remission:
- IV hydrocortisone
- IV ciclosporin (immunosupressant) if no response to steroids after 72 hours
- Infliximab
- Consider surgery
Add on therapy/maintenance:
- Infliximab/adalimumab/golimumab/ vedolizumab
- AND azathioprine/mercaptopurine
When would a topical treatment be appropriate and what drugs can have a local effect?
5-ASA and steroids
Enemas for left sided
Suppositories for rectum
Budesonide has different indications due to its different formulations. What are the following indicated for and why?
- Cortiment
- Endocort/Budenofalk
- Cortiment is for UC as it is released in the colon
2. Entocort/Budenofalk is for CD as it is released in terminal ileum/colon
What drugs have a fast onset for IBD?
Steroids
5-ASA
Anti-TNFs
Ciclosporin
What drugs have a slow onset for IBD?
How long do they take to have an effect?
Azathioprine
Mercaptopurine
Methotrexate
2-3 months for onset of action
What 2 IBD drug classes interact with heart failure?
Steroids - fluid retention
Biologics - can worsen HF
What IBD drug class interacts with diabetes?
Steroids can affect glycaemic control
What should you make sure in osteroporosis IBD patients in terms of their steroid treatment?
Avoid repeated course of steroids
What are the extra intestinal effects of IBD?
Pyoderma - skin disease
Arthopathy - disease of joints
How often should methotrexate be given?
Once a week
How long do you need adequate contraception for after stopping methotrexate?
3-6 months
What serious side effects come with methotrexate use?
Cirrhosis
Pulmonary fibrosis
What should be prescribed with methotrexate?
Folic acid 5mg once weekly on a different day to methotrexate
