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159 Cards in this Set
- Front
- Back
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Why are antidiarrheals not used in severe UC?
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contribute to development of toxic colonic dilation
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What kind of nutrition in severe acute ulcerative colitis and CD?
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enteral nutrition, may induce remission
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What is advantage of perenteral nutrition?
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allows complete bowel rest in severe UC, lead to remission in CD
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What nutrition if fistulas?
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parenteral
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What are probiotics?
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reestablishment of normal bacterial flora in gut by PO of live bacteria (E. coli, bifidobacteria, lactobacilli, Strep. thermophilus)
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Do more CD or UC need surgery?
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CD (70-80%)
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Is proctocolectomy curative?
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yes for UC, no for CD
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Where is site of action of sulfasalazine?
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colon
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Where is site of action of olsalazine?:
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colon
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Where is site of action of balsalazide?
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colon
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Where is site of action of Rowasa (mesalamine)?
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rectum and distal colon
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Where is site of action of Asacol (mesalamine)?
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distal ileum and colon
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Where is site of actionof Pentasa (mesalamine)?
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small bowel and colon
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Where is site of action of Lealda (mesalalmine)?
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colon
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Where is site of action of Canasa (mesalamine)?
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rectum
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What are pH dependent mesalamine?
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Asacol and Lialda
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Which is enema?
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Rowasa
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Which is suppositor?
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Canasa
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Are IBD drugs curative?
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no
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What is active component of sulfasalazine?
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mesalamine
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What is MOA of aminosalicylates?
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block production of prostaglandins and leukotrienes, inhibit bacterial peptide induced reactive oxygen metabolites, and inhibit activation of nuclear regulatory factor nuclear factor kappa B
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When is suppository or enema mesalamine used?
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proctitis
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What is the slow release PO form of mesalamine?
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Pentasa
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How does pH dependent Lialda work?
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releases drug evenly throughout the colon
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Which med is a dimer of 2 5-ASA molecules?
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olsalazine
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How does olsalazine work?
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mesalamine is released in colon after colonic bacteria cleave olsalazine
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What is a prodrug of mesalamine?
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balsalazide
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Which 5-ASA can't be used with sulfonamide allergy?
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sulfasalazine
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How do corticosteroids work in UC and CD?
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modulate immune system and inhibit production of cytokines and mediators
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What oral CS is used?
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budesonide
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Why doesn't budesonide have any systemic effects?
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extensive first pass metabolism
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What immunosuppressive agent are used in IBD?
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azathiprine, mercaptopurine, MTX, cyclosporine
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How long for results from azathioprine or mercaptopurine?
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few weeks to 6 months
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When are immunosuppresives used?
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if refractory to steroids
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What AE from azathioprine or mercaptopurine?
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lymphomas, pancreatitis, nephrotoxicity
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What immunosuppressive for acute severe UC?
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cyclosporine continuous IV infusion
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What AE for cyclosporine?
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nephrotoxicity and neurotoxicity
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When is MTX used?
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maintenance of CD, not UC, weekly IM dose
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When is tacrolimus used/
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fistulizing CD
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Are antimicrobials used in CD or UC?
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CD only
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What antimicrobial is used mostly in CD?
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metronidazole
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How does metronidazole work in CD?
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unsure, interruption of a bacterial role in the inflammatory process
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What antimicrobial has shown some efficacy in UC and CD?
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rifaximin
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When is infliximab used?
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moderate to severe active disease and steroid dependent or fistulizing disease, expensive
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How does infliximab work?
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IgG MAB the binds TNF-alpha and inhibits inflammatory effect in gut
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What can be used if pt loses response to infliximab?
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adalimumab
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What route for infliximab?
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IV
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What rout is adalimumab?
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SQ
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infliximab
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Remicade
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adalimumab
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Humira
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How long for tx with parenteral steroids before trying cyclosporine or colectomy?
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7-10days
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How often are mesalamine suppositories and enemas used to maintain remission?
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every 3rd night
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Is PO/topical combo more effective in UC tx?
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yes
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What used to prevent relapse in UC?
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5-ASA
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Are CS used in maintenance tx?
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no
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What is used to lower or eliminate CS use in CS dependent pt?
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azathioprine, mercaptopurine, or infliximab
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What must be given with cyclosporine tx?
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azathiprine or mercaptopurine
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Is infliximab used for maintenance?
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yes, if there is initial response
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When is metronidazole used in CD?
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not responding to sulfasalazine
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When is budesonide used in CD?
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ileal or right sided colonic disease
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What is topical hydrocortisone used for in CD?
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distal colonic inflammation
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When are systemic CS not effective in CD?
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perianal fistulas
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When is MTX used in CD?
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induce remission and reduce CS dependency
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When is infliximab used in CD?
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mod/severe when not responding to CS or immunosuppressive
fistulas when not responding to AB, immunosuppressive, or surgical drainage |
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When is cyclosporine used?
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high doses for short term efficacy in active disease
IV effective for fistulizing disease |
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Are CS used for maintenance in CD?
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no
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Is budesonide used shorterm or longterm?
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shor term maintenancy , 3 months
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What is effective for maintenance of remission regardless of disease distribution?
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azathioprine or 6-mercaptopurine
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What is tx for perianal or enteric fistulae?
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azathioprine or 6-mercaptopurine
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What is 1st line for mild-moderate disease UC?
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PO sulfasalazine or mesalamine derivative
if distal disease: topical mesalamine |
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What AE from sulfasalazine?
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dose related: GI, HA, arthralgia
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Is mesalamine more effective than sulfasalazine?
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same
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Why is olsalazine not first choice?
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AE: severe diarrhea from direct osmotic effect to induce small bowel fluid secretion
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How far to suppositories reach?
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10-20cm, use for proctitis only
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How far do enema formulations reach?
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splenic flexure, can use for distal disease
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When are CS used in UC?
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if unresponsive to sulfasalazine or mesalamine
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Why are PO steroids not used for initial tx for mild-mod UC?
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risks of steroid use
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Can rectal steroid be used initially for mild/mod UC?
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yes
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Is rectal mesalamine or rectal steroids more effective at inducing remmission in mild/mod UC?
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mesalamine
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When is infliximab used in mild/mod uc?
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unresponsive to steroids or other immunosuppressive agents
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Is nicotine good in UC or CD?
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UC only, may improve symptoms in mild/mod active UC, use as adjunctive therapy
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Does severe UC need hospitalization?
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yes, NPO to rest bowel
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Are sulfasalazine and mesalamine derivative effective in severe UC?
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no, diarrhea doesn't allow enough time for gut bacteria to cleave the molecules
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What is first line for severe UC?
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IV hydrocortisone in 3 divided doses or methyprednisolone daily
methylprednisoline typically preferred because of lesser mineralocorticoid effects |
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How long to withdraw from CS?
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usually over 3-4 weeks to avoid hypoadrenal crisis because of adrenal suppression
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When should cyclosporine be started in severe UC?
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unresponsive to 7-10 days of parenteral corticosteroids
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What are main drugs for maintenance remission?
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sulfasalazine and mesalamine
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Is sulfasalazine or olsalazine more effective at maintaining remission?
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sulfasalazine
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Are steroids used in maintenance of remission?
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no, not effective
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Can azathioprine be used for maintenance of remission?
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yes, may take 3-6 months for benefit
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Can infliximab be used for maintenance of remission?
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yes, if initially responded to infliximab
5mg/kg every 8 weeks |
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What is initial tx in mild/mod CD with ileal, ileocolonic, or colonic involvement?
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mesalamine or sulfasalazine
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What is first line for mild to moderate ileal or right sided CD?
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CS (budesonide)
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Are systemic steroids used for tx of perianal fistulas?
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no
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When is metronidazole used in CD?
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colonic or ileocolonic involvement, perineal disease
usually adjunct to musalamine or steroid |
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What other AB used in CD?
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cipro
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Is metro/cipro combo used?
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efficacious in perianal disease
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When are immunosuppressives used in mild/mod CD?
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pts not achieving adequate response to standary medical therapy or reduce steroid dose
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What is AZA metabolite?
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mercaptopurine
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What labs monitored when starting immunosuppressives?
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CBC with diff every 2 weeks
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How long for therapeutic effects from azathioprine and mercaptopurine?
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3-4 months
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What is clinical response to 6-mercaptopurine related to?
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concentration of metabolite 6-thioguanine
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What is toxic response to 6-mercaptopurine related to?
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6-methylmercaptopurine concentration
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What inactivates metabolites of azathioprine and mercaptopurine?
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TPMT
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What if TPMT defficient?
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greater risk of bone marrow suppression
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Can MTX be used for induction of remission of CD?
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yes
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What AE from MTX?
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bone marrow suppression, hepatotoxicity, pulmonary toxicity
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When is infliximab used in CD?
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moderate/sev failing immunosuppressive, CS dependent, tx of fistulizing disease
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When is cyclosporine used in CD?
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only for acute management of pts with severe fistulizing disease
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What is long term risk of cyclosporine?
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renal toxicity and infection
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Is prevention of recurrence more difficult in CD or UC?
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CD
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Are sulfazalazine or mesalamine used in maintenance of remission?
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can try if induce remission with
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Are steroids used in maintenance of remission of CD?
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no
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What is first line immunosuppressive for maintenance of remission of CD?
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azathioprine and mercaptopurine
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When is MTX used for maintenance of remission of CD?
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pts that initially respond to it
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What is the most effective maintenance of remission for fistulizing CD?
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infliximab
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When is adalimumab used for maintenance in CD?
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if unresponsive to conventional therapies
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What is tx for toxic megacolon?
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supportive care: fluids, blood replacement, broad spectrum AB (cover gram negative bacilli and intestinal anaerobes) if perforation x 2-3 weeks
high dose IV steroid (hydrocortisone, methyprednisolone, corticotropin) x 2 weeks colectomy with formation of ileostomy after fail max tx = 3-7 days |
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What meds d/c in toxic megacolon?
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opiates and anticholinergic because enhance colonic dilation
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What are common systemic manifestations of IBD?
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arthritis, anemia, skin manifestations (erythema nodosum and pyoderma gangrenosum), uveitis, liver disease
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What causes anemia in IBD?
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loss of blood in GI
malabsorption of B12 or folic acid |
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What is tx for anemia?
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if po: ferrous sulfate
npo: blood transfusions or IV iron infusion B12 and folic acid if deficient |
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When should screening for osteoporosis begin?
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if on steroids for 3 months, postmenopausal, male older than 50, sustained low stress fracture
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What is given if pt is high risk for osteoporosis?
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Vit D and calcium
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What is given if osteoporosis present?
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Vit D, calcium, and bisphosphonates
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What is arthritis tx in IBD?
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aspirin or NSAID (may exacerpate IBD), steroids also may be beneficial
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What can be used for ankylosing spondylitis, erythema nodosum, and pyoderma gangrenosum?
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infliximab
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What about pregnancy in IBD?
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risk of spontaneous abortions, risk of low birth weight
little effect on pregnancy |
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What drugs can be given in pregnancy for IBD?
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CS and sulfasalazine
infliximab can be given metronidazole in short courses |
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What is given with sulfasalazine in pregnancy?
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interferes with folate absorption
1mg folic acid BID |
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What effect does sulfasalazine on males?
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decrease sperm counts
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What med shouldn't be used in pregnancy?
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MTX, abortifacient
immunosuppressive associated with fetal deformities |
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What med shouldn't be given if nursing?
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metronidazole
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What AE from sulfasalazine?
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GI: n/v/d anorexia
HA, arthralgia (dont require d/c) idosyncratic: rash, fever, hepatotoxicity (require d/c) uncommon/serious: bone marrow suppression, thrombocytopenia, pancreatitis, pneumonitis, interstitial nephritis, hepatitis |
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How do mesalamine AE compare to sulfasalazine?
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less
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What AE for olsalazine?
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watery diarrhea
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Why greater chance of AE form CS?
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high doses used for extended periods
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CS AE?
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hyperglycemia, HTN, osteoporosis, acne, fluid retention, electrolyte disturbances, myopathies, muscle wasting, increased appetite, psychosis, reduced resistance to infection
adrenocortical suppression |
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How to minimize CS AE?
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alternate day steroid therapy
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How long for withdrawal CS?
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2-3 week taper
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What type A AE for azathioprine and mercaptopurine?
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dose related: malaise, nausea, infectious complications, hepatitis, myelosuppression
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What causes myelosuppression in immunosuppressives?
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deficiency in TPMT and accumulation of toxic metabolite
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What are type B AE for azathioprine and mercaptopurine?
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idiosyncratic: fever, rash, arthralgia, pancreatitis
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Which immunosuppressive has fewer lymphomas?
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mercaptopurine
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What DI for mercaptopurine?
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allopurinal, reduce mercapto dose
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Metronidazole AE?
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mild: nausea, metallic taste, urticaria, glossitis
serious/longterm: paresthesia, reversible peripheral neuropathy disulfiram like reaction |
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What AE for infliximab?
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infusion reactions, serum sickness, increase in serious infections (sepsis, TB)
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What should pt receive before receiving infliximab?
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TB skin test and chest radiograph
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Who shouldn't receive infliximab?
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active infections, severe or decompensated disease (worsen HF)
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What AE for adalimumab?
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same as infliximab
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What is the most common scale used to measure quality of life in IBD?
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IBD questionaire
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sulfasalazine MOA
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unknown, antiinflammatory and immunomodulatory properties
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mesalamine MOA
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unknown, topical rather than systemic
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azathioprine (Imuran) MOA
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antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteine
mostly by 6-thioguanine |
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mercaptopurine
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purine antagonist that inhibits DNA and RNA synthesis
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metronidazole (flagyl) MOA
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loss of helical DNA structure and inhibit protein synthesis
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infliximab (Remicade) MOA
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TNF alpha blocker
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Adalimumab (Humira) MOA
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TNF alpha blocker
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nadalizumab (Tysabri) MOA
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decreases inflammation by binding to alpha 4 integrin, blocking adhesion and migration of leukocytes in the gut
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