IBD tx

Question 1

Mild-mod active UC by area

Answer 1

-4-6 stool/d
-minimal systemic sx
-left-sided disease = reach of edemas
-proctitis = suppository
-extensive disease pancolitis (beyond splenic flexure): requires systemic tx

-combo oral and topical mesalamine can be more effective

Question 2

Mild-mod active UC

Answer 2

-oral/topical ASAs
-if unresponsive, consider changing formulation
-if unresponsive to standard dose ASA or mod dx = high dose mesalamine (>3g/d) + RECTAL mesalamine
-CR budesonide is alt (nonresponsive to ASA or can add), limit <8-16 weeks
-prednisone for pt refracotry to ASA (not maintenance)
-topical corticosteroid for distal disease

Question 3

Mild-mod distal dx UC tx

Answer 3

-oral ASA
-enema mesalamine (left-sided)
-suppository mesalamine (procitis)

-remission:
-consider reducing ASA dose

Question 4

Mild-mod EXTENSIVE UC tx

Answer 4

-oral mesalamine
+/- CR budesonide
-prednisone if refractory

-remission:
-consider reducing dose
-d/c budesonide < 8 weeks

Question 5

Mod-severe active UC

Answer 5

-4-6 stools per day
+/- blood in stool
-some systemic sx

Question 6

Mod-severe active UC induction

Answer 6

-5-ASA (mod only)
-budesonide (mod)
-prednisone (mod-severe)
-consider TNFa/biologics/small molecules if unresponsive or steroid dependent

Question 7

Induction and maintenance in mod-severe active UC

Answer 7

-TNF (inflix, adalimumab, golimumab)*NOT certolizumab
-vedolizumab (anti-a)
-IL12-IL23
-JAK
-S1P

Question 8

Step-up approach to mod-severe active UC

Answer 8

-early use of advance tx than slow step up
-extent of bowel involvement shouldn’t limit access to advanced tx in mod-severe
-tx mild-mod that is unresponsive to ASA or w risk factors associated w hospitalization/surgery like mod-severe disease

Question 9

If infliximab use in mod-severe UC

Answer 9

-combo w thiopurine/immunomodulator
-any TNF not just infliximab?

Question 10

mod-severe active UC considerations

Answer 10

-thiopurine monotherapy is option for maintenance NOT induction
-MTX should NOT be used for mx OR induction
-corticosteroids not mx
-recommend against adding 5-ASA to biologic if failed ASA

Question 11

SLIDE 114

Answer 11

SLIDE 114

Question 12

Severe-Fulminant UC

Answer 12

-6-10stools/d
-blood present
-systemic sx
-inpatient tx

Question 13

Severe-Fulminant UC tx

Answer 13

-consider NPO (bowel rest)
-IV corticosteroid (methylprednisone or hydrocortisone) then PO
-if unresponsive to IV steroids, consider TNF (infliximab) or cylosporine

Question 14

Cyclosporine and infliximab for fulminant UC

Answer 14

-cylosporine: start IC, transition to PO, then transition to 6-MP or AZA
-may delay rather than prevent colectomy
-infliximab similar efficacy

Question 15

UC mx of remission

Answer 15

-ASA (mod only)
-AZA or 6-MP if unresponsive/steroid dependent (slow to work 3-6mo)
-TNF if required TNF for induction of if failed azathioprine (can combo w AZA)(NOT certolizumab)

-vedolizumab
-IL12/23
-JAK (only if failed TNF)
-S1P

-if pt fail ASA, stop using ASA

Question 16

UC tx in pt naive to advanced tx

Answer 16

1. Higher efficacy:
   -infliximab
   -vedolizumab
   -ozanimod
   -estrasimod
   -upadacitinib
   -risankizumab
   -guselkumab
2. intermediate:
   -golimumab
   -ustekinumab
   -tofacitinib
   -mirikizumab
3. low efficacy:
   -adalimumab

Question 17

UC tx in pt who failed an advanced tx (esp TNF)

Answer 17

1. Higher efficacy:
   -tofacitinib
   -upadacitinib
   -ustekinumab
2. intermediate efficacy:
   -gilgotinib
   -mirikizumab
   -risankizumab
   -guselkumab
3. lower efficacy:
   -adalimumab
   -vedolizumab
   -ozanimod
   -etrasimod

Question 18

mild-mod active CD

Answer 18

-sulfasalazine marginally effecive for tx COLONIC CD:
-CR budesonide for distal/right-sided dx
-diet mods in v mild dx

-antibiotics:
-metronidazole +/- cipro
-variable efficacy
-option in perianal, fistulizing dx, unresponsive to sulfasalazine
-not primary tx

Question 19

Mod-severe active CD

Answer 19

-failed tx for mild-mod, systemic sx
-CDAI 220-450?
-prednisone>budesonide until resolution of sx and wt gain
-IV steroids in hospital

-TNF-a:
-pt failing immunosuppressants/steroid dependent
-can combo w AZA or MTX

-vedolizumab (SC)
-natalizumab not preferred (only if JC -)
-IL12/23
-JAK (upadacitinib if fail TNF)

-AZA/6-MP monotherapy for mx only not induction

-MTX IM/SC for mx

-AVOID cyclosporine, 5-ASA, sulfasalazine

Question 20

Severe-fulminant CD characteristics

Answer 20

-persistent sx/toxicity despite steroid/biologic tx
-cachexia
-rebound tenderness
-obstruction
-abcess
-CDAI >450
-inpt tx

Question 21

Severe-fulminant CD tx

Answer 21

-consider NPO
-supportive care
-IV steroids if no abscess, then PO
-consider infliximab (or other biologic)

Question 22

CD mx of remission

Answer 22

-can try sulfasalazine and mesalamine but rarely effective, AVOID in mod-severe
-limit budesonide < 4mo
-AZA and 6-MP goof in steroid or infliximab induced remission
-MTX alt to AZA and 6-MP, esp initial response to MTX (SQ only)
-TNF combo w immunomodulators
-vedolizumab not natalizumab
-IL-12/23
-JAK (upadacitinib if fail TNF)