pharmacology > IBS/IBD > Flashcards

IBS/IBD Flashcards

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1
Q

what is IBS?

A

Idiopathic chronic relapsing disorder with abdominal discomfort and change in bowel habits

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2
Q

What is the goal with txt of IBS?

A 
relieve symptoms (constipation, diarrhea, abd pain/bloating) and improve bowel function
-we don't know what causes it so we just txt symptoms
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3
Q

IBS is a chronic ____ not a chronic _____ condition. what does this mean for us when txting it?

A

chronic relapsing not chronic progressive
- although we want to give comfort, careful with meds as risks can outweigh benefits (b/c we’re not decreasing morbidity/serious complications with our treatment anyways)

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4
Q

IBS what are some examples of food triggers vs natural fiber sources ?

A

food trigger example: raw veges, caffeine, carbonation, fructose and sorbitol
natural fiber example: Beans (navy, kidney, pinto); broccoli, celery, apples, pears, strawberries

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5
Q

_______ can improve abdominal pain and global symptoms

They may be considered for patients with moderate to severe symptoms

A

anti-depressants

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6
Q

three main categories of IBS

A

constipation, diarrhea, abdominal pain/bloating

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7
Q

all three kinds of mild IBS are treated with ?

A

education, stress management, diet and exercise

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8
Q

moderate IBS-C txt options

A

Osmotic Laxative: Polyethylene glycol (Miralax)

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9
Q

severe IBS-C txt options (2)

A

Prescription Laxative:

  1. Chloride Channel Activator : lubiprostone
  2. Guanylate Cyclase-C Agonist: linaclotide, plecanatide
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10
Q

moderate IBS-D txt options (2)

A

Antidiarrheal Agent:

  1. Loperamide
  2. Bile Acid Sequestrants
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11
Q

severe IBS-D txt options: (2)

A

Antibiotic : rifaxamin

5-HT3 antagonist : Alosetron

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12
Q

moderate IBS- abd pain/bloating txt options (3)

A

Antispasmodic:

  1. Peppermint oil
  2. Dycyclomine
  3. Hyoscyamine
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13
Q

severe IBS-abd pain/bloating txt options (2)

A
  1. TCAs: Amitriptyline

2. SSRIs: -cytalopram and fluoxetine

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14
Q

3 groups of drugs we can use for IBS

A

antidepressants, antispasmotics, probiotics

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15
Q

antidepressants can be used for ____

while antispasmotics can be used for _____

A

both txt abdominal pain but in addition…

antidepressants: global symptoms
antispasmodics: acute attacks of pain or before meals for postprandial symptoms

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16
Q

what two probiotics can we use for IBS?

A

(lactobacillus & bifidobacterium)

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17
Q

what can probiotics do for IBS?

A

Reduces IBS symptoms
Improve abdominal pain, bloating, flatulence
Help to restore normal GI flora

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18
Q

IBS D&C w/ abd pain: txt as a ____ syndrome . first line and second line drugs?

A

chronic pain
first line: antidepressants (TCAs)
second line: antidepressants (SSRIs)

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19
Q

what TCA-antidepressant do we go to for IBS D&C w/pain? what properties of this drug are helpful for this kind of IBS and how?

A

Amitriptyline
-Anticholinergic properties of TCA are helpful at decreasing motility & GI secretions without affecting mental status

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20
Q

dosage of TCAs (Amitriptyline) for IBS?

A

-Low dosage (10-50mg for IBS vs 150mg or more for depression) decreases adverse effects

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21
Q

what are the SSRIs we use for second line IBS D&C w/ pain?

A

Paroxetine (Paxil); Citalopram (Celexa); Fluoxetine (Prozac)

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22
Q

the_______ are anticholinergics

A

antispasmodics

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23
Q

what are the 2 antispasmodic drugs we use?

A

Dicyclomine (Bentyl)
Hyoscyamine (Levsin)

(“mine”)

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24
Q

MOA of anti-spasmodics?

A

Inhibiting muscarinic input in the enteric plexus & on smooth muscle
Decreases contractility of intestinal smooth muscle

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25
peppermint oil can be useful for what kind of IBS? what are the 2 products we can use?
IBS D&C w/ abd pain | pepogest and IBgard
26
MOA of peppermint oil products (pepogest and IBgard)?
Blocks calcium channels causing relaxation of GI smooth muscle
27
pepogest and IBgard: take ____ a day. when?
3 times a day (before meals)
28
5 drugs utlized for IBS w/ diarrhea
Loperamide (Imodium) - anticholinergic, opiod binding Diphenoxylate (Lomotil) -anticholineric and opiod binding- combined with atropine b/c potential for abuse Rifaximin (Xifaxan) Eluxadoline (Viberzi) Alosetron (Lotronex) *however, diarrhea often gets better on its own. so question whether these are really needed/helpful
29
MOA of Rifaximin (Xifaxan)
Inhibits bacterial RNA synthesis by binding to bacterial DNA-dependent RNA polymerase
30
Abs and excretion of Rifaximin
Minimally absorbed, eliminated unchanged in feces
31
what do we use Rifaximin for?
IBS w/ diarrhea | Patients see improvements in IBS symptoms and bloating
32
MOA of Alosetron (Losenox) ?
Inhibit 5-HT3 receptor to decrease pain sensation from gut to spinal cord, inhibit motility & increase transit time of bowel. End result decrease nausea, bloating, pain, and diarrhea
33
which drug... "Approved for IBS with severe diarrhea AND Reserved for women with severe, chronic IBS-D that is unresponsive to other drugs "
Alosetron (losenox) - a 5HT3 inhibitor * (dont really know why only women- but men wont generally be prescribed it)
34
ADRs Alostetron (Losenox)?
rare but significant - constipation requiring hospitalization and ischemic bowel- sometimes fatal
35
what is the REMS policy?
means a drug is only prescribed by those with special training. This is in regards to Alostetron for IBS as the ADRs are significant and dangerous.
36
MOA of Eluxadoline (Viberzi)
1. Mu & Kappa opioid receptor agonist Leads to decreased muscle contractility Inhibition of water and electrolyte secretion Increase rectal sphincter tone 2. targets Delta opioid receptor antagonist Reduce iatrogenic constipation and abdominal pain
37
what drug do we use for IBS w/ diarrhea that targets ALL components of the opiod receptor? what schedule of controlled substances is this?
Eluxadoline (Viberzi) | - a schedule IV controlled substance
38
Eluxadoline (viberzi) is contraindicated in pts w/...
Contraindicated in patients with biliary duct, pancreatic duct, or GI tract obstruction
39
ADRs of eluxadoline (Viberzi)
going to far on the anti-diarrheal
40
zofran for IBS
Also a 5HT3 receptor antagonist | only helps with IBS diarrhea (can be very constipating), no help with abdominal pain.
41
bile acid sequstrants for IBS
Cholestyramine (Questran) May increase colonic transit time and improve IBS symptoms *these are also use for cholesterol
42
what is our first choice agents for IBS-C (mild)?
bulk forming agents: reduce strain and soften stools
43
what are the bulk-forming agents? (4)
Psyllium (Metamucil); Methylcellulose (Citrucel); Polycarbophil (Fibercon); wheat dextrin (Benefiber)
44
what can a pt take if bulk-forming agents aren't working for IBS-C?
1. osmotic Lax (polyethylene glycol aka miralax) - ok for longterm use 2. Cl- Channel activators or GCC agonists can also use... Stood softeners (docusate); colonic stimulants (bisacodyl, senna)
45
what Cl-channel activator do we use for severe IBS-C?
Lubiprostone (Amitiza)
46
what GCC agonist do we use for severe IBS-C?
Linaclotide (Linzess) or trulance
47
Inflamm. bowel disease includes what two disorders
crohns and UC
48
Inflamm bowel disease: Symptoms can be similar to IBS but have evidence of ______, ______ and _______. What contributes to the ongoing inflamm. process?
Symptoms can be similar to IBS but have evidence of bowel inflammation (bleeding, weight loss, elevated inflammatory markers (ESR &CRP) & abnormality on endoscopy or biopsy - inflammatory CtKs contribute to ongoing inflammatory process (IL-1, IL-6, TNF)
49
UC vs crohns? where in the gut do they have an impact?
UC- colon | crohns- localized areas all throughout small and large intestine
50
contributory factors for inflamm bowel disease (Weeds)
genetic association with first degree relatives, defects in intestinal epithelial barrier and immune system, environmental (NSAIDS, smoking, and diet worsen IBD)
51
what is fulminant IBD?
more severe, abrupt onset - pateint will present more systemically with different symptoms (>10 stools per day compared to mild which is <4 per day)
52
IBD: how many stools per day: mild, moderate, severe, fulminant
mild: <4 moderate: >4 severe: >6 w/ blood fulminant: >10 w/ continuous blood (increasing signs of systemic toxicity starting at moderate)
53
drugs used for mild IBD
Aminosalicylates Topical Corticosteroids for proctitis Budesonide for ileitis
54
drugs used for moderate IBD
Immunomodulators : Azathioprine & 6-mercaptopurine Methotrexate Cyclosporin Oral Corticosteroids TNF inhibitors
55
drugs used for severe IBD
IV Corticosteroids Cyclosporine Integrin Receptor Antagonist Interleukin 12 & 23 Antagonist
56
3 additional options for IBD txt?
Antibiotics Prebiotics Probiotics
57
what are aminosalicylates used for?
Used for the induction and maintenance of remission in mild to moderate ulcerative colitis and Crohn’s disease Contain 5-aminosalicylic acid (5-ASA) -mesalamine
58
two types of aminosalicylates
Mesalamine (5ASA) | Azo compounds
59
5 ASA works ______ in GI tract with ______ absorption. Therefore...
work topically in GI, with little systemic Abs. | therefore not many ADRs( except one), but also dont have anti-inflammatory activity once they are absorbed
60
which 5ASA has significant ADRs and what are they?
Sulfasalazine (one of the azo compounds)- Only azo compound broken down into 5ASA (Mesalamine) and an ACTIVE component- sulfapyridine. ``` Rash and fever Hepatitis AGRANULOCYTOSIS Pancreatitis Reversible oligospermia (decreased sperm production) ```
61
proposed MOA of 5 ASAs (Weeds)
Thought to inhibit prostaglandin and Leukotriene synthesis and inhibit TNF
62
Why are brand names important for the 5ASA-(Mesalamine) agents? what are the different brand names?
brand name is more important than usual b/c it means a different formulation. (released in colon at different times based on pH ) - Pentasa - Asacol - Lialda - Rowasa/Canasa (RC PAL)- Rectal Colon & pals
63
Mesalamines: Avoid administration with antacids because they ______ and ______. Similar interaction could occur with _____ and ______.
change stomach pH and cause premature dissolution of coating. PPI and H2-receptor antagonist
64
What are the significant differences in the different 5 ASA (Mesalamines)? (pentasa, asacol, lialda, rowasa/canasa)
Pentasa: oral extended time release: releases throughout the small intestines and colon. Asacol & Lialda: pH dependent resin: ileum to proximal colon/rectum Rowasa or Canasa: enema and suppository; works topically on rectum and sigmoid colon
65
what are the three different 5ASA- Azo compounds? and of the three which is broken down into 5 ASA and an active compound?
"Salazines" Sulfasalazine (Azulfidine) breaks down into 5 ASA and sulfapyridine Olsalazine (Dipentum) breaks down into 5-ASA & an inactive compound Balsalazide (Colazal)- 5-ASA & inactive compound
66
Azo compound MOA
5ASA bound to another molecule to allow passage through the small intestine When the azo compounds reach the terminal ileum & colon broken down by an enzyme found there called azo reductase Overall: works only througout Colon (proximal to rectum)
67
what is the pH range from jejunum, through small intestine, colon, to rectum?
jejunum around 6.5 .. gets gradually more neutral... | distal colon and rectum around 7
68
When do we use topical glucocorticoids for IBD?
mild to moderate UC and Crohn’s | -for acute flares,not useful for maintaining disease remission.
69
what are the topical glucocorticoids that we use for IBD?
Hydrocortisone enemas, foam or suppositories, topical budesonide
70
what are the major benefits to using topical glucocorticoids?
maximize local tissue effect & minimize systemic absorption
71
what is a special, powerful glucocorticoid | About 15 times more potent than prednisone?
budesonide
72
when changing from prednisone to budesonide, allow for a ____ overlap. why?
2 week. b/c of HIGH first pass metabolism of budesonide, it wont be biologically available until 2 weeks. (good for little systemic effect)
73
what are the two formulations of budesonide that we use for IBD? what do we use each for?
Entocort EC (oral) is for mild to moderate Crohn’s involving the ileum and/or ascending colon Uceris (oral & rectal foam) if for mild to moderate ulcerative colitis
74
what are the 4 immunomodulatory agents for IBD?
Azathioprine & Mercaptopurine Methotrexate Cyclosporine Tacrolimus (Prograf)
75
MOAs of the immunomodulatory agents for IBD? (Azathioprine/mercaptopurine, methotrexate, cyclosporine, tacrolimus)
Azathioprine & Mercaptopurine: inhibits purine synthesis. anti-proliferative effects and induce t-cell apoptosis Methotrexate: inhibits DNA synthesis. repair and cellular replication contributing cell death Cyclosporine: inhibits production & release of IL-II and prevents IL-II activation of T-lymphocyctes Tacrolimus (Prograf) : same as Cyclosporine ?..
76
which drug can we use for moderate/ severe steroid dependent and steroid resistant crohns?
methotrexate (an immunomodulatory agent)
77
which drug can we use for severe steroid dependent and steroid resistant UC?
cyclosporine | or maybe tacrolimus
78
For methotrexate, what is the dosing?
once a week! if they take more than once a week it cacn be deadly (even if they're breaking up a dose between days)
79
major ADR for azathioprine and mercaptopurine?
hepatotoxicity and myelosuppression (bone marrow suppression)
80
what are the 4 TNF-Alpha antagonist agents for IBD? when do we utilize these?
``` Infliximab (Remicade) Adalimumab (Humira) Certolizumab (Cimzia) Golimumab (Simponi) Used for moderate to severe ulcerative colitis and/or Crohn’s not responsive to conventional therapies ( A STEP UP THERAPY, NOT FIRST CHOICE) ```
81
what does TNF-alpha normally do? (aka why do we want to antagonize it?) (weeds)
TNF-α causes release of proinflammatory cytokines from macrophages, t-cell activation, leukocyte migration
82
ADRs of TNF alphas
Infusion reactions, increased risk for serious infections (TB, fungal infections, opportunistic infections (legionella & Listeria);bone marrow suppression, reactivation of hepatitis, heart failure exacerbations (significant but Cleveland did not highlight in class)
83
What are the two integrin receptor antagonists for IBD? when do we use these?
Natalizumab (Tysabri) Vedolizumab (Entyvio) - b/c of rare but significant ADRs, we only use these as a last resort
84
MOA of natalizumab and vedolizumab?
ALPHA-4 INTEGRIN ANTAGONIST: Alpha-4 integrin is on leukocytes that mediates adhesion to endothelial receptors and migration into the intestine BLOCKING THIS REDUCED INFLAMMATION
85
what are integrins?
Integrins are cell adhesion molecules and help leukocyte infilatration .
86
for any biologic, it is important to test for _____ prior to prescribing.
TB, as these can cause reactive latent TB
87
ADRs of natalizumab and vedolizumab?
rare hepatic toxicity & progressive multifocal leukoencephalopathy (PML)- a demyelinating disease causing leisons due to polyomavirus (rare but significant)
88
what is the IL- 12 &23 antagonist ?
Ustekinumab (Stelara)
89
MOA of Ustekinumab (weeds)
Biological effects of IL-12 and IL-23 include natural killer (NK) cell activation, CD4+ T-cell differentiation and activation. Binds to and blocks IL 12 & 23 preventing activation of inflammatory and immune response
90
when would we use ustekinumab?
Used for moderately to severely active Crohn’s disease in adults who were intolerant/unresponsive to immunomodulators, steroids or TNF inhibitor
91
ADRs of ustekinumab? (major ones) (weeds.. maybe)
vulvovaginal candidiasis, TB, non-melanoma skin cancer
92
what three Abx may we use for IBD? why would we look to use these?
1. metronidazole (flagyl) 2. ciprofloxacin (cipro- a fluoroQ) 3. Rifaximin (Xifaxan) Bacteria plays role in IBD and ABX treatment helpful, particularly in Crohn’s
93
what bacteria do each of the Abx treat? (flagyl, cipro, rifaximin) (weeds)
flagyl: anaerobic cipro: gram + and gram - rifaximin: gram + and gram -
94
which Abx do we NOT want to use longterm?
flagyl
95
which Abx has significant ADRs and which has none?
bad: Cipro (tendon rupture, QT prolong, hypoGlyc.) good: Rifaximin (acts locally in gut)
96
what is our general approach to IBD treatment?
1. Identify Severity: Active (mild to fulminant) or remission 2. Determine extent and location of disease 3. pick a drug based on ... (4 criteria)
97
4 Criteria for IBD drug
Onset of action Formulation (topical, oral, parenteral) Effectiveness Potential adverse effects or contraindications
98
IBD txt recommendation: mild-moderate Crohns
Aminosalicylate or Budesonide (ileal) +/- topical Left sided: Enema Rectal: Suppository
99
IBD txt recommendation: mild-moderate UC
Aminosalicylate or Budesonide +/- topical Left sided: Enema Rectal: Suppository
100
IBD txt recommendation: moderate- severe Crohns
1. TNF-⍺ inhibitor with Azathioprine/6-MP or methotrexate +/- 2. Corticosteroids (short-term) 3. Vedolizumab or Natalizumab (last line)
101
IBD txt recommendation: moderate- severe UC
``` 1. TNA-⍺ inhibitor +/- 2. Azathioprine/6-MP +/- 3. Corticosteroids (short-term) ``` 4. Vedolizumab (last line)
102
ADR: TNF alpha antagonist
Infection Risk (screen for TB/Viral Hepatitis) Risk of Heart Failure or exacerbation Hepatosplenic T-cell lymphoma when used with azathioprine or 6-MP in young male patients Antibody formation Infusion reactions
103
ADR: anti motility agents
Risk of toxic megacolon in active disease
104
ADR: Azathioprine/6-MP
Bone marrow suppression, pancreatitis, hypersensitivity Check TPMT activity (poor metabolizer = ↑ drug concentration Lymphoma when combined with TNF-⍺ inhibitor
105
ADR: Methotrexate
Bone marrow suppression, pulmonary and hepatic toxicity | Pregnancy - teratogen
106
ADR: corticosteroids
Adrenal suppression, metabolic effects, infection
107
ADR: natalizumab & vedolizumab
Progressive multifocal leukoencephalopathy (PML)
pharmacology
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