IBD Therapy

Question 1

How do lifestyle factors affect Crohn’s ?

Answer 1

Smoking aggravates Crohns:
-worse disease outcome
-more rapid recurrence post-surgery

Diet not implicated in pathogenesis, but can influence symptoms

Question 2

What diet should be recommended in IBD ?

Answer 2

Balanced healthy diet recommended

Stricturing &/or fistulating Crohn’s disease
-low residue (fibre) diet
-elemental diet (e.g. Modulen)
-strict gut rest (e.g, parenteral nutrition)

Question 3

Outline acute and maintenance drug therapies for acute and management in Crohn’s and UC

Answer 3

All therapies have anti-inflammatory effects

Question 4

What are different types of corticosteroids and how are they administered ?

Answer 4

Methylprednisolone/Hydrocortisone
-Intravenous
-Rquires in-patient admission for 5 days then oral switch

Prednisolone
-Oral/topical
Outpatient therapy

Budesonide
-Oral/topical
-Outpatient therapy

Question 5

How are corticosteroids used in IBD ?

Answer 5

Systemic anti-inflammatory properties lead to rapid induction of remission of acute flares
-Short course; High dose initially, reducing over 8 weeks
-Accrete D3 for bone protection while taking steroids
-Not a long term maintenance therapy
-Use as ‘bridge’ to maintenance therapy or step up if changing maintenance treatments

Steroid dependence exists

Question 6

What are side effects of steroids ?

Answer 6

Musculoskeletal
-avascular necrosis
-osteoporosis

Gastrointestinal
-hyperphagia

Cutaneous
-acne/folliculitis
-thinning of skin

Metabolic
-weight gain
-diabetes
-hypertension

Neuropsychiatric
-drug induced psychosis
-depression

Cataracts

Growth failure (<18y)

Question 7

What are 5-ASAs ?

Answer 7

5-Aminosalicylic acids, only used in ulcerative colitis

Anti-inflammatory properties
-decreases cyclooxygenase & lipoxygenase pathways
-reduces formation of pro-inflammatory prostaglandin and leukotriene molecules

Reduces risk of colon cancer

Requires renal function monitoring

Question 8

What are side effects of 5-ASAs ?

Answer 8

Side effects:
diarrhoea, idiosyncratic nephritis

-Requires renal function monitoring

Question 9

How are different forms of 5-ASAs used ?

Answer 9

Oral
-pro-drugs
-pH dependent release
-delayed release

Topical
-suppositories
-enemas

Question 10

Give examples of different forms of 5-ASA drugs

Answer 10

Question 11

When is Immunosuppression used in IBD ?

Answer 11

When more potent suppression of inflammation required
-UC: patients on 5ASA but requiring > 2 courses steroids in 12 months
-Crohn’s disease: maintenance therapy

Examples include:
-Thiopurines (azathioprine / 6-mercaptopurine)

Question 12

What are side-effects of Azathioprine & 6-mercaptopurine (thiopurines) ?

Answer 12

Pancreatitis
Leucopaenia
Hepatitis
Small risk of lymphoma, skin cancer

Immunosuppresants used in IBD

Question 13

Profile use of Azathioprine & 6-mercaptopurine (thiopurines)

Answer 13

Slow onset of action (16 weeks)
Metabolised in liver by thiopurine methyltransferase (TPMT) activity contributes to toxicity in slow metabolisers
Avoid co-prescription of allopurinol (XO inhibitor)
Regular blood monitoring required (FBC, LFTs)

Question 14

What is Tumour Necrosis Factor α ?

Answer 14

A proinflammatory cytokine

Question 15

What is Anti-TNF therapy ?

Answer 15

Biologic used in both UC & Crohn’s
-Promote apoptosis of activated T- lymphocytes
-Rapid onset of action; Rescue therapy in acute in-patient presentations and Maintenance treatment
-Useful in fistulating & perianal Crohn’s disease

Biologics = antibodies

Question 16

Explain different forms of biologic Antibodies directed against TNFα and how they are administered

Answer 16

Chimeric
-e.g. infliximab
-iv infusion, s/c injection

Humanised
-e.g. adalimumab
-s/c injection

Question 17

What are JAK inhibitors ?

Answer 17

Janus kinase inhibitors
-Block phosphorylation & activation of Signal Transducer & Activator of Transciption (STAT) of cytokines
-Licensed UC & Crohn’s
-E.g. Tofacitinib, Upacitinib, Filgotinib

Tablet, quick acting

Aren’t

Question 18

What must be monitored when JAK inhibitors are being used ?

Answer 18

Monitor
-CVS risk (lipid profile)
-Thromboembolic events (DVT/PE)
-Infections (Herpes zoster)
-Teratogenicity
-Renal/liver/FBC monitoring

Question 19

Outline the ‘top-down’ therapy approach in IBD

Answer 19

Question 20

When is surgery used in IBD ?

Answer 20

Emergency
-Failure to respond to medical therapy, small bowel obstruction, abscess, fistulae

Elective
-Failure to respond to medical therapy
-Dysplasia of colon mucosa

Question 21

Outline the use of surgery in Crohn’s

Answer 21

-Minimise amount of bowel resected
-Not curative
-Repeated resection of small intestine can result in ‘short gut syndrome’ and requirement of lifelong total parenteral nutrition (reduced life expectancy)

Question 22

Outline the use of surgery in ulcerative colitis

Answer 22

-Curative
-Option of permanent ileostomy or restorative proctocoloectomy and pouch

Question 23

Summarise IBD treatment

Answer 23