1
Q
clinical and pathological features of UC
the ones bolded by Letassy are starred
A
- continuous distribution
- RARELY ileal and transmural involvement
- crypt abscesses VERY common
- NO cobblestone appearance
- uncommon: malaise, fever, abd pain
- rare: aphthous/linear ulcers, strictures, fistulas
- rectal involvement is common
2
Q
clinical and pathological features of CD
the ones bolded by Letassy are starred
A
- discontinuous distribution
- ileal involvement VERY common
- Transmural involvement common
- crypt abcesses RARE
- cobblestone appearance common
- common: malaise, fever, abd pain, strictures, fistulas, aphthous/linear ulcers
- rectal involvement is rare
3
Q
proctitis
A
-UC disease confined to the rectum
4
Q
proctosigmoiditis
A
-UC disease extending to the sigmoid colon only
5
Q
distal disease (left-sided colitis)
A
-UC disease that only reaches to the splenic flexure
6
Q
extensive disease (pancolitis)
A
-extends to entire colon
7
Q
What classifies a UC patient as mild
A
- <4 stools/day +/- blood
- no systemic complications
- normal ESR (0-30 mm/h)
8
Q
What classifies a UC patient as moderate
A
- > 4 stools/day with blood
- minimal systemic complications
9
Q
What classifies a UC patient as severe
A
- > or equal to 6 stools/day with blood and cramps
- evidence of systemic complications as indicated by:
- fever (>37.5 C)
- tachy (>90 BPM)
- anemia (<10.5 g/dl)
- ESR > 30 mm/hr
10
Q
What classifies a UC patient as fulminant
A
- > 10 stools/day with continuous bleeding, toxicity, abd pain and tenderness, distension, fever, anorexia, may require transfusions
- pts are at risk of progressing to toxic megacolon and bowel perf
11
Q
Crohn’s disease classification: asymptomatic remission
-note: CDAI = Crohn’s disease activity index)
A
- CDAI <150
- pts who are asymptomatic either spontaneously or after a medical/surgical intervention
- pts requiring steroid to remain asymptomatic are NOT considered to be in remission but are referred to as “steroid-dependent”
12
Q
Crohn’s disease classification: mild/moderate
A
- CDAI: 150-219
- ambulatory pts able to tolerate diet w/o manifestation of dehydration, systemic toxicity, abd tenderness, painful mass, intestinal obstruction or >10% weight loss
13
Q
Crohn’s disease classification: moderate/severe
A
- CDAI: 220-450
- pts that fail to respond to tx for mild/moderate dz or have more prominent sx of: fever, weight los, abd pain/tenderness, intermittent N/V (w/o obstruction) or anemia
14
Q
Crohn’s disease classification: severe/fulminant
A
- CDAI: >450
- presence of persistent sx despite outpatient corticosteroid or biologic tx OR evidence of systemic toxicity: high fevers, persistent vomiting, intestinal obstruction, significant peritoneal signs, presence of cachexia or abcess
15
Q
what are the goals of tx for CD and UC?
A
- resolve the acute/active inflammatory process (induce clinical remission)
- resolution of local and systemic complications
- maintain remission
- surgical palliation or cure
- improve quality of life
16
Q
In which disease is surgery NOT curative?
A
- CD
- however may be used to manage dz
17
Q
In which disease IS surgery curative?
A
- UC
- indicated when dz is uncontrolled on optimized medical therapy or for management of complications
18
Q
class: 5-ASA (aminosalicylic acid) derivative
- list the drugs (4)
A
- sulfasalazine
- mesalamine
- olsalazine
- balsalazide
19
Q
class: corticosteroids
- list drugs (6)
A
- hydrocortisone
- prednisone
- budesonide (CIR)
- budesonide-MMX
- hydrocortisone IV
- methylprednisolone IV
20
Q
class: immunosuppressants
- list drugs (4)
A
- azathioprine
- 6-mercaptopurine
- cyclosporine
- methotrexate
21
Q
class: biologics (TNF-alpha inhibitors)
- list drugs (3)
A
- infliximab (remicade)
- adalimumab (humera)
- certolizumab (cimzia)
22
Q
class: anti-integrin abs
- list drugs (2)
A
- natalizumab (tysabri)
- vedolizumab (entyvio)
23
Q
what is the preferred 5-ASA derivative?
A
mesalamine (better tolerated than sulfasalzine)
24
Q
oral vs topical mesalamine
A
- oral: used for extensive disease
- topical: used for distal disease or proctitis
25
mesalamine drug interactions
avoid:
- antiacids
- H2RAs (ranitidine/famotidine)
- PPIs
-safe to use in pts w/ sulfa allergy
26
sulfasalazine MoA
- combo of sulfapyridine and mesalamine
- it is cleaved into those 2 products, mesalamine being the active one
- but true MoA is not well understood
27
sulfasalazine vs mesalamine
-sulfasalazine is commonly used vs oral mesalamine b/c of low cost BUT it's not well tolerated
28
sulfasalazine contraindications
-sulfa allergy
29
counseling points for sulfasalazine
- it impairs folic acid absorption
| - take a supplement (1 mg/day)
30
What is the sulfasalazine product brand name?
Azulfidine
31
mesalamine ORAL products
- list 2
- what formulation
- pentasa: controlled-release capsule
| - lialda: delayed and extended release tab, multimatrix (UC and CD)
32
mesalamine TOPICAL products
- list 2
- what formulation
- canasa: 1 g suppository
| - rowasa: 2g-4g retention enema
33
Canasa counseling points
- reserved for proctitis
- BID to induce remission
- administered at bedtime to maintain remission
34
Rowasa counseling points
-enemas reach to the splenic flexure and can be used for distal disease AND proctitis
35
balsaladize products
- list 2
- formulation
- colazal: capsule
| - giazo: tab
36
given the dosage form, indicate what part of the colon it will reach
- enema: will reach proximal sigmoid colon and splenic flexure
- foam prep: will reach mid-sigmoid colon (1/2 way)
- suppositories: distal 5-8 cm of rectum
37
oral agents coverage of colon
- review chart on pg 11
- Pentasa covers almost everything
- lialda covers all of the colon
38
MoA of corticosteroids
modulate the immune system and inhibit production of cytokines and inflammatory mediators
39
general comments on corticosteroids
- use for ACUTE management only - not desirable for maintenance/chronic use
- rectal formulations: used in distal dz
- oral: used in more extensive dz not responding to oral 5-ASA
- IV: reserved for those w/ s/s of systemic complications and severe dz not responding to other therapies
40
ADRs of corticosteroids
- HPA axis suppression
- increase risk of infection
- immunosuppression
- increase in glucose
- increase WBC
- increase BP
- weight gain
- edema
- alteration in mood/insomnia
- osteoporosis (long term)
41
what is an important counseling point for corticosteroid?
do not stop abruptly
42
hydrocortisone
- list products (2)
- formulations
- what type of dz they tx
- cortenema: enema; reserved for proctitis or distal dz
| - cortifoam: foam enema; reserved for proctitis or distal dz
43
budesonide CIR
- list product
- formulation
- what dz tx
- entocort: PO - controlled release into the ileum (think CD)
- first-line for CD confined to the ileum and/or right colon
44
budesonide-MMX
- list product
- formulation
- what dz tx
- uceris: PO delayed release and extended release tab, multimatrix, controlled release into colon
- extends the release of the drug into the colon for use in mild/moderate UC
45
What type of pt are immunosuppressants used in?
- those who are steroid dependent
- refractory to steroids or
- for attaining remission in those w/ inadequate response to 5-ASA derivatives
46
general comments on immunosuppressants
- used in conjunction w/ mesalamine derivative and/or steroids
- must be used long-term (months) before benefits are seen, so NOT acute relief
- may be steroid-sparing
- counsel pts that it may take months to see benefits
47
ADRs of azathioprine
- hepatosplenic T-cell lymphoma
- neutropenia
- hepatotoxicity
- nephrotoxicity
- myelosuppression
48
6-mercaptopurine ADRs
- hepatosplenic T-cell lymphoma
- neutropenia
- hepatotoxicity
- nephrotoxicity
- myelosuppression
49
cyclosporine ADRs
- hyperglycemia
- nephrotoxicity
- HTN
- neurological toxicity
50
methotrexate ADRs
- myelosupression
- hapatotoxicity
- pulmonary toxicity
51
when to use methotrexate
-after mercaptopurine or cyclosporine
52
What are the antibiotics used to tx UC and CD? (2)
- metronidazole
| - cipro
53
important fact before starting a TNF-alpha inhibitor
- must r/o TB before using them
| - they can reactivate latent disease
54
notes on infliximab (remicade)
- development of abs to infliximab
- can lead to serious infusion reactions or loss of response to drug
- reduce formation of these by giving a 2nd dose w/i 8 weeks of initial dose, concurrent admin of steroids and use of concomitant immunosuppressive agents
55
general comments on anti-integrin antibodies
- used in tx of CD for pts who are unresponsive to other therapies
- should NOT be used in combo w/ immunosuppressants or TNF-alpha inhibitors
- ADR: PML (progressive multifocal leukoencephalopathy)
56
In a pt w/ mild to moderate UC who is experiencing a flare, what is the best medication and dosage form?
- topical 5-ASA (mesalamine)
- induce remission in >90% of pts
- proctitis: supp
- proctosigmoiditis: enema
57
maintenance therapy in a FIRST epidsode of mild proctitis
NOT recommended
58
when is maintenance therapy recommended in UC?
- in pts w/ UC who have more than 1 relapse a yr
| - in ALL pts w/ proctosigmoiditis
59
given a pt w/ mild/moderate UC that is more extensive, what is the appropriate combo of meds to induce and maintain remission?
-note: this includes left sided colitis (distal dz), extensive colitis, and pancolitis
1. oral 5-ASA
- all mesalamine products are equally effective
- balsalazide may be slightly better
2. 5-ASA or steroid suppository
3. steroid enemas or foam
60
What is the advantage of budesonide MMX over oral prednisone?
it is designed to release budesonide in the colon
61
note on severe/fulminant UC tx
- Letassy doesn't have a LO for this
- but there are things highlighted from her packet
- maybe review pg 17 for this?
62
What prophylactic tx is needed for pts hospitalized w/ UC and CD
heparin to prevent DVTs
63
given a pts w/ mild/moderate Crohn's dz, what is the appropriate first line tx to induce remission?
- of the ileum and proximal colon:
| - enteric coated budesonide (entocort)
64
given a pts w/ mild/moderate Crohn's dz, what is the appropriate alternative tx to induce remission in a pt who cannot tolerate first line tx?
prednisone
65
What is the advantage of budesonide CIR over oral prednisode in CD?
less systemic effects
66
adjunct therapies in crohn's dz
- antidiarrheals: loperamide
- BAS if chronic watery diarrhea
- probiotics: NO evidence
- lactose avoidance: can help decrease sx
- eliminate other food triggers
GI 2
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