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92 Cards in this Set

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What is IBS?
Irritable bowel syndrome; gastroinestinal syndrom characterized by chronic abdominal pain and altered bowel habits in the absence of an organic cause
What is IBD?
inflammatory bowel disease; two types: ulcerative colitis (inflammatory condition confined to the rectum and colon) and crohn's disease (inflammatory condition of the GI tract that can affect any part from the mouth to the anus)
What are the S/sx of IBS?
lower abdominal pain, ab bloating and distention, extreme urgency, mucous passage, psychosocial symptoms such as depression and anxiety
What are the two types of IBS?
IBS-D or diarrhea predominant: >3stools/d; IBS-C or constipation predominant: <3 stool/wk, straining, incomplete evacuation
What are the S/sx of Ulcerative colitis?
abdominal cramping, frequent bowel movements often with blood in the stools, weight loss, fever and tachycardia in severe disease, hemorrhoids and fissures, decreased hematocrit and hemoglobin, increased erthrocyte sedimentation rate
What are the S/Sx of crohn's disease?
Malaise and fever, ab pain, frequent bowel movements, hematochezia, fistula, weight loss, increased white blood count and erythrocyte sedimentation rate
What are the two types of IBS diag criteria?
Manning and Rome III
What are the characteristics of the Manning IBS diag criteria?
Chronic or recurrent ab pain for at least 6 months and two or more of the following: ab pain relieved by defecation, ab pain associated with more freq stools, ab pain associated with looser stools, ab distension, feeling of incomplete evacuation after defecation, mucus in stools
What are the characteristics of the Rome III IBS diag criteria?
Recurrent ab pain or discomfort at least 3 d per month in the last 3 months associated with 2 or more of the following: relieved with defecation, onset associated with a change in freq of stool, onset associated with change in form (appearance) of stool
What other tests can be used to rule out other causes than IBS?
sigmoidoscopy or colonoscopy, stool tests for occult blood or ova or parasites, CBC, erythrocyte sedimentation rate, electrolytes, other imagining studies
What is the IBD diag criteria for classification of mild ulcerative colitis?
fewer than 4 stools per day with or without blood; no systemic disturbances and normal erythrocyte sedimentation rate
What is the IBD diag criteria for classification of moderate ulcerative colitis?
more than 4 stools per day but with minimal systemic disturbances
What is the IBD diag criteria for classification of severe ulcerative colitis?
more than 6 stools per day with blood, evidence of systemic disturbances (fever, tachycardia, anemia, or erythrocyte sedimentation rate >30)
What is the IBD diag criteria for classification of fulminate disease ulcerative colitis?
more than 10 stools per day, continous bleeding, toxicy, abdominal tenderness, need for a blood transfusion
What is the IBD diag criteria for classification of mild-moderate crohn's disease?
ambulatory and no evidence of dehydration, systemic toxicity, weight loss, or abdominal tenderness
What is the IBD diag criteria for classification of moderate-severe crohn's disease?
failure to response to treatment for mild to moderate disease, fever, weight loss, abdominal pain, significant anemia
What is the IBD diag criteria for classification of severe/fulminate crohn's disease?
persistent symptoms despite steroids or use of biologic agents (TNF-a antagonists), cachexia, rebound tenderness, intestinal obstruction, or abscess
What is the IBD diag criteria for classification of symptomatic remission crohn's disease?
patient is asymptomatic or without symptomatic inflammatory issues; does not include patients controlled on steroids
What is the pathophys of IBS?
unknown; thought to be CNS processing abnormailites of afferent signal processing may lead to visceral hypersensitivity. Serotonin is currently being studied as the receptors involved particularly in diarrhea predominant
What are factors that can lead to IBS?
genetics, motility factors, inflammation, colonic infections, mechanical irritation due to local nerves, stress, or psychosocial factors
What are the dietary treatments for IBS?
fiber: 1 tbsp with 1 meal/d and increase gradually to 2-3 meals/d; if fiber is not tolerated may substitute bulking form agents such as psyllium
What are the two mentioned antispasmodics used for treating IBS?
dicyclomine and hyoscayamine
What is the MOA of the antispasmodics?
anticholonergic agent which decreases GI motility
What are the adverse effects of antispasmodics?
dry mouth, nausea, constipation, dizziness, syncope, insomnia, blurred vision, urinary hesitancy, tachycardia, sweating
What are the drug interactions with antispasmodic agents?
antihistamines (increase SEs of antispasmodics), antiglaucoma meds (antispasmodics decrease the effects of the antiglaucoma meds)
What is the MOA of loperamide?
increase intestinal transit time, enhances water and electrolyte absoprtion, and strengthens rectal sphincter tone by binding to the opiate receptor in the gut wall
What are the adverse effects of loperamide?
constipation
What is the brand name of loperamide?
imodium
What is the brand name of Tegaserod?
Zelnorm
What is the moa of Tegaserod?
Serotonin-4 agonist in the GI tract leading to increased GI motility and decrease visceral sensations
What are the adverse effects of Tegaserod?
diarrhea and some reports of CV events (not on the market; have to do special paperwork)
What are the drug interactions of Tegaserod?
no clinical significant interactions
What is the indication for Tegaserod?
women in constipation predominant IBS
What is the brand name for Alosetron?
Lotronex
What is the moa of Alosetron?
serotonin-3 antagonist
What are the adverse effects of Alosetron?
constipation, ischemic colitis
What are the drug interactions of Alosetron?
fluvoxamine and 3A4 inhibitors
What is the indication for Alosetron?
women with diarrhea predominant IBS symptoms of longer than 6 months not relieved by conventional therapy
What is the moa of lubiprostone?
c-2 chloride channel activator; causes chloride secretion into the intestine which causes sodium to enter the lumen and water follows
What are the adverse effects of lubiprostone?
nausea, diarrhea, HA
What are the drug interactions of lubiprostone?
no clinically significant interactions
What is the indication for lubiprostone?
women with constipation dependent IBS
What are the three types of adjunct tx for IBS?
tricyclic antidepressants, SRIs, Rifaximin
What is the moa of tricyclic antidepressants in adjunct tx for ibs?
modulates perception of visceral pain, alters GI transist time, and maybe treatment underlying psychosocial issues
What is the moa of rifaximin in adjunct tx for ibs?
works by decreasing gut bacteria and bacteria products that lead to IBS symptoms and may alter the bacteria and host response to the bacteria's effect
What are the potential etiologies of IBD?
infections, genetics, environmental factors (diet, smoking: protective in Ulcerative colitis but risk factor in crohn's), immune defects, psychological factors
What is the current theory behind the pathophys of IBD?
defects in the immune system allow bacteria into the gut mucosa which causes an exaggerated immune response which leads to bowel damage
What are the differences between Crohn's and ulcerative colitis in terms of anatomic sites involved?
ulcerative colitis involves the rectum and colon only while crohn's is in the terminal ileum most commonly but may occur anywhere and sites may be discontinuous
What are the differences between Crohn's and ulcerative colitis in terms of depth of involvement?
ulcerative colitis affects the mucosa and submucosa only usually while crohn's affects the bowel wall leading to extensive injury and has intestinal lumen narrowing
Between crohn's and ulcerative colitis, which usually has cobblestone appearance upon colonscopy?
crohn's disease
What is the treatment focus in IBD?
agents to reduce the inflammatory process, nonpharmacologic tx are just as important, adjunct tx may be needed to treat the complications of these disorders
What are the non-pharmacological types in tx of IBD?
nutritional support and surgery
What are the characteristics of nutritional support in IBD tx?
used to prevent malnutrition, have patient watch for foods that exacerbate sysmtoms (lactose intolerance is a common problem), enteral and parenteral nutrition may be needed
Is surgery curative for ulcerative colitis?
it can be
Is surgery curative for crohn's?
no
What is the moa of aminosalicylates in tx of IBD?
block production of prostaglandins and leukotrienes, inhibit central peptide induced neutrophil chemitaxis, scavenge reactive oxygen metabolites, but true moa is unknown
How can mesalamine be superior to sulfasalazine in some case?
pts with sulfa allergy
What are the adverse effects of sulfasalazine?
most of the effects are due to the sulfapyridine portion so less side effect with mesalamine; dose related sides include N/V, diarrhea, anorexia, HA, arthralgia, folic acid deficiency; also idiosyncratic effects of rash, fever, hepatotoxicity, bone marrow suppression, thrombocytopenia, pancreatitis, hepatitis
What are the drug interactions with sulfasalazine?
decrease absorption of folic acid and digoxin
What are the drug interactions with mesalamine?
no clinically significant interactions
What is the MOA of corticosteroids in IBD?
modulate immune systems and inhibit production of cytokines and mediators
What are the adverse effects of steroids in IBD?
hyperglycemia, hypertension, osteoporosis, acne, fluid retention, electrolyte disturbances, myopathies, muscle wasting, increased appetite, reduced resistance to infection, adrenocortical suppression
What are the drug interactions of corticosteroids?
hepatic enzyme inducers increase the clearance of steroids while inhibitors decrease cl
What are the two immunosuppressive agents used in IBD?
azathiopurine and mercaptopurine
What is the moa of azathiopurine or mercaptopurine in IBD tx?
unknown
What are the adverse effects of azathiopurine or mercaptopurine in IBD tx?
Dose related (type a): malaise, nausea, infectious complications, hepatitis, myleosuppression; idiosyncratic (type b): fever, rash, arthralgia, pancreatitis, lymphomas, nephrotoxicity
What is the moa of cyclosporine in ibd tx?
inhibits the action of t-cells
What are the adverse effects of cyclosporine?
nephrotoxicity, tremor, hirsutism (a condition where women have excess facial and body hair that is dark and coarse), hypertension
What are the drug interactions of cyclosporine?
drugs that increase cyclosporine conc: calcium channel blockers, antifungals, erythromycin abxs, steroids; drugs that decrease cyclosporine conc: naficillin, rifampin, phenytoin, phenobarbital, carbamazepine, st john's wart
Which condition in IBD is cyclosporine predominantly used?
ulcerative colitis; mainly a rescue therapy to avoid surgery, only works in pts who respond to azathiopurine
What is the moa of antimicrobials in IBD tx?
may interrupt the bacterial role in the inflammatory process
Which type of IBD is antimicrobials indicated in?
crohn's disease not ulcerative colitis
What are the adverse affects of antimicrobials in IBD tx?
nausea, metallic taste, urticaria (flagyl)
What drug interactions does flagyl present in ibd tx?
increase effects of warfarin, disulfiram rxn
What are the possible SEs with TNF-a blockers in IBD tx?
infusion rxns, serum sickness, increase infections, reactive antibodies to TNF-a blockers (only occurs in infliximab) that renders tx useless
What are the drug interactions of TNF-a blockers?
watch in combination with other immunosuppresive agents
What is the MOA of selective anti-adhesion molecules (natalizumab/Tysabri)?
blocks adhesion and subsequent leukocyte migration into the gut
What are the adverse effects of selective anti-adhesion molecules (natalizumab)?
progressive multifocal leukoencephalopathy
In ulcerative colitis, what is the tx recommendations for mild to moderate disease in distal disease?
topical mesalamine agents are superior to oral aminosalicylates or steroids and the combination of oral and topical aminosalicylates is more effective than either agent alone
In ulcerative colitis, what is the tx recommendations for mild to moderate disease in colitis?
Sulfasalazine or oral mesalamine; steroids are only used in pts who are not responding to above tx or who need quick relief of sx; if not responding to steroids, consider azathiopurine or 6-mercaptopurine as long as patient is not acute enough to need iv therapy; infliximab is last line
In ulcerative colitis, what is the tx recommendations for severe disease?
if the pt is refractory to max tx with pred, oral aminosalyciate therapy, and topical meds then pt should be started on infliximab as long as immediate hospitalization is not needed; if toxicity is present then pt should be admitted for iv steroids; if not improvement in 3-5 days the pt should be considered for colectomy or IV cyclosporine
What is the remission tx in distal ulcerative colitis?
mesalamine suppositories or enemas are the most effective, can also use sulfasalazine or mesalamine oral, combining oral and topical mesalamine may be most effect, DO NOT use steroid for remission, if these agents all fail then tryL 6-mercaptopurine, azathiopurine, or infliximab
What is the remission tx in colitis for ulcerative colitis?
sulfasalazine or mesalamine can all be used, DO NOT treat chronically with steroids, azathiopurine or 6-mercaptopurine should be considered in pts who can not get off steroids
What is the remission tx in severe ulcerative colitis?
addition of 6-mercaptopurine to the regimen may be helpful, may need to consider longterm infliximab
What is the tx for ileocolonic or colonic mild crohn's?
sulfasalzine or oral mesalamine
What is the tx for perianal mild crohn's?
sulfasalazine or oral mesalamine and/or metronidazole
What is the tx for small bowel mild crohn's?
oral mesalamine or metronidazole. Budesonide (entrocort) for terminal eleal or ascending colonic disease
What is the tx for moderate crohn's?
same as mild plus prednisone 40-60mg/d, if refractory and fistulizing disease add infliximab; taper pred after 2-3 wks if improved, if not add azathiopurine, mercaptopurine, or methotrexate or switch to adalimumab
What is the tx for severe crohn's?
Hydrocortisone 100mg IV q 6-8h, if no response in 7 days add cyclosporine IV 4mg/kg/d
What is the tx for remission maintenance in crohn's?
start with sulfasalazine and mesalamine derivatives but seems to be less effective then in ulcerative colitis, again steroids should not be used for remission, may consider immunosuppressant agents
What are the possible complications of ulcerative colitis?
toxic megacolon, colonic perforation, colonic hemorrhage, colonic stricture, clon cancer, liver complications, joint complications, ocular complications, dermatologic and mucosal complications
What are the possible complications of crohn's disease?
small bowel strictures and obstructions, fistual formation, colon cancer but risk is not as high as with ulcerative colitis, joint complications, ocular complications, dermatologic and mucosal complications, gallstones, nutritional deficiencies (wt loss, iron deficiency anemia, vit b12 deficiency, folate deficiency, hypoalbuminemia, hypokalemia)