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IBD
inflammatory bowel disease
| Question | Answer |
|---|---|
| which diease is smoking better for and which is it bad for | smoking is good for ulcerative colitis and bad for crohn's disease |
| Use of nonsteroidal anti-inflammatory drugs (NSAIDs)exacerbates with condition | has been associated with exacerbation of IBD |
| IBD is divided into two major disorders: | ulcerative colitis (UC) and Crohn's disease (CD). |
| Although both UC and CD are generally considered diseases of the young when do you see peaks | 20-40 and 60-80 yo |
| Whatever the mechanism, it is now generally agreed that the symptoms of IBD result | from dysregulation of the mucosal immune system |
| what are the three major theories of the cause IBD | combination of infections, genetic, and immunological causes, psychological factors and environmental factors |
| UC usually presents as shallow, *continuous* inflammation of the colon ranging from | limited forms of proctitis (*rectal* involvement only) to involement of the whole colon |
| what is the pathology typical in UC | *Crypt abscesses* rectal involement* consisting of accumulations of polymorphonuclear neutrophil (PMN) cells, necrosis of the epithelium, edema, hemorrhage, and surrounding accumulations of chronic inflammatory cells. |
| signs not present in UC | Fistulas, fissures, abscesses, and small bowel involvement are not present |
| Most patients with UC experience a chronic, intermittent course of disease. Chronic, loose, bloody stools are the most common symptom of UC | most common symptom of UC |
| The inflammation in UC is limited to the . | mucosa, which presents as friable, granular, and erythematous, with or without ulceration |
| common complaints of ulcerative colitis include | tenesmus (urge to defecate) and abdominal pain. |
| Mild UC is defined as | fewer than four stools a day, no systemic signs of toxicity, and a normal erythrocyte sedimentation rate (ESR). |
| Moderate disease is characterized by | more than four stools a day but minimal evidence of systemic toxicity. |
| Severe disease is defined as | more than six bloody stools a day, fever, tachycardia, anemia, and/or an ESR >30. |
| CD is a | chronic, transmural, patchy, granulomatous, inflammatory disease that can involve the entire GI tract, from mouth to anus, with discontinuous ulceration (so-called “skip lesions”), fistula formation, and perianal involvement. |
| what is the most commonly affected area in crohn's diease | terminal ileum is most commonly affected |
| the most common pathological features associated with crohn's diease that ulcerative colitis doesn't have are | ileal involvement, strictures, fistulas, transmural involvement, granulomas, linear clefts, cobblestone appearance |
| Unlike UC, the severity of the disease does not correlate directly with | the extent of bowel involvement |
| what the primary determinants of the disease course and the nature of complications | patterns and there are three kinds predominantly inflammatory, stricturing, or fistulizing |
| surgery may be curative in which one as surgery in ___ is usually followed by relapse | UC curativeCD recurrent disease after surgery is high |
| IN UC Patients usually present with | abdominal pain and chronic, often nocturnal, diarrhea.2,4,18 Weight loss, low-grade fever, and fatigue are also common. Features such as abdominal masses or abscesses and fistula (an abnormal communication between two organs) |
| where are fistulas present | Enterocutaneous and enterorectal fistula are common, but other types, such as enterovaginal, can occur. Fistula can be excruciatingly painful, can be a source of infection, and can also exert significant psychosocial distress |
| which usually present with toxic megacolon | Ulcerative colitis |
| mild-to-moderate CD is defined as | ambulatory patients who are able to tolerate oral feeding without signs of systemic toxicity. |
| Moderate-to-severe CD is defined as | patients with symptoms of fever, weight loss, abdominal pain, nausea and vomiting, and/or significant anemia. |
| sulfasalazine adverse effects include | nausea, vomiting, headache, alopecia, and anorexia. A significant number of patients discontinue this medication because of dose-dependent adverse effects. ADR are because the drug is absorbed systemically but plays no role in therapy |
| idiosyncratic adverse effects sulfasalazine include | hypersensitivity rash, hemolytic anemia, hepatitis, agranulocytosis, pancreatitis, and male infertility. This poor adverse effect profile has led to the development of safer sulfa free compounds that contain only 5-ASA. aminosalicylate, mesalamine |
| -mesalamine enema rowasa, pentasa | -distal colitis |
| -canasa suppository | -proctitis |
| -The oral 5-ASA agents are effective in | -inducing remission in mild-to-moderate UC and for maintaining remission in UC and perhaps for mild CD confined to the colon. |
| Adverse effects of the oral 5-ASA compounds include | diarrhea (especially with olsalazine), headache, arthralgias, abdominal pain, and nausea. Interstitial nephritis has rarely been reported with chronic use of mesalamine, but the association remains controversial. |
| Corticosteroids are the most commonly used agents in the treatment of | acute flares in patients with moderate-to-severe IBD |
| First-line treatment for moderate-to-severe active UC includes doses of | corticosteroid equivalent to 40 to 60 mg of prednisone. |
| An important drug interaction is the possibility of increasing 6-mercaptopurine levels in patients receiving | balsalazide |
| Corticosteroids are not effective and should be avoided for maintenance therapy of | CD and UC |
| Topical steroids (enemas, foams, and suppositories) are beneficial for | distal colitis and can serve as an adjunct in patients with rectal disease that also have more proximal disease and have failed topical 5-ASA therapy. |
| Oral enteric-coated budesonide is approved for the treatment of | CD. Budesonide possesses a high degree of topical anti-inflammatory activity with low systemic bioavailability. |
| The Entocort EC formulation of budesonide delivers drug primarily to the | ileum and ascending colon. |
| Immunomodulators commonly used for the management of steroid-dependent and quiescent IBD. | Azathioprine and 6-mercaptopurine (6-MP) are |
| what is the MOA of Azathioprine | is converted to 6-MP, then metabolized to thioinosinic acid, the active agent that inhibits purine ribonucleotide synthesis & cell proliferation, alters the immune response by inhibiting NK cell activity & suppressing cytotoxic T-cell function. |
| are used in the treatment of active UC and CD in patients whose conditions have not responded to systemic steroids. | Azathioprine (2–3 mg/kg/day) and 6-MP (1–1.5 mg/kg/day) upt to 3 to 4 months may be required to obaserve response |
| azathioprine and 6-MP are also used as maintenance therapy for both UC and CD and may be used as | “steroid-sparing” agents in patients unable to be weaned from corticosteroids. B/C of the long onset of action of 6-MP and azathioprine, Doc's induce remission with either corticosteroids or infliximab and use these agents for maintaining remission. |
| Adverse effects of 6-MP/azathioprine | include rash, nausea, pancreatitis, and diarrhea. |
| Myelosuppression, especially neutropenia, may have a delayed onset, and clinicians should monitor | the complete blood count monthly for the first 3 months of treatment, then every 3 months thereafter |
| Methotrexate (MTX), MOA | a folate antagonist, impairs DNA synthesis. It may also reduce interleukin-1 (IL-1) production or induce apoptosis of selected T-cell populations. |
| 30 MTX appears to be ineffective for induction or maintenance of UC.38 However, data suggest that MTX (15–25 mg IM weekly) may have a role in | both initial and chronic treatment of CD. |
| The onset of effect often takes weeks to months with MTX. Most experts and recent guidelines suggest reserving MTX use for ` | patients with CD intolerant of, or refractory to, 6-MP/azathioprine treatment |
| Adverse effects with MTX include | stomatitis, neutropenia, nausea, hypersensitivity pneumonitis, alopecia, and hepatotoxicity. MTX-induced nausea and stomatitis may be prevented by the addition of folic acid 1 mg PO daily. hepatotoxicity may be ameliorated by folate use. |
| Cyclosporine (CSA), which selectively inhibits T-cell-mediated responses, has advantages over azathioprine, 6-MP, and MTX because of its | more rapid onset of action. |
| Both oral and IV forms have been used to manage severe | UC. Due to serious adverse effects, CSA is usually reserved for patients with severe UC refractory to corticosteroids |
| WHAT has been used in severe steroid-refractory UC | (CSA)cycloporine 4 mg/kg IV daily |
| Tubercular infections, including reactivation of latent disease are a particular concern with ________, and patients should be appropriately screened for latent disease before starting infliximab treatment. | infliximab |
| Infliximab is a recombinant chimeric monoclonal antibody that | binds to human TNF-α and neutralizes its biological activity by binding with high affinity to both soluble cell receptors and free TNF-α in the blood. |
| infliximab is indicated for | inducing and maintaining remission in patients with moderate-to-severe active CD who have had an inadequate response to conventional treatment. |
| infliximab is also effective for | healing CD fistula, with data showing that chronic treatment can maintain fistula closure and decrease the need for surgery. |
| Most recently, infliximab received an indication for | the induction and maintenance of moderate-to-severe UC refractory to other treatment |
| For all indications, infliximab is given as a | 5 mg/kg IV infusion over 2 hours. |
| An induction regimen, administered at 0, 2, and 6 weeks | is followed by a maintenance infusion every 8 weeks. |
| The response to infliximab is usually | rapid, often occurring within several days |
| Because infliximab is a monoclonal antibody, ADR associated with therapy include | a number of immunologic-mediated adverse effects |
| Immediate infusion-related reactions such as | fever, chills, pruritus, urticaria, and (rarely) severe cardiopulmonary symptoms can occur |
| Use of infliximab with concomitant immunosuppressives, such as azathioprine, | decreases the development of these antibodies. |
| Infectious complications, including pneumonia, cellulitis, sepsis, cholecystitis, endophthalmitis, furunculosis, and reactivation of tuberculosis and histoplasmosis, have been reported with what drug | infliximab |
| Tubercular infections, including reactivation of latent disease are a particular concern with infliximab, and patients should | be appropriately screened for latent disease before starting infliximab treatment |
| Adalimumab is approved for the treatment of _____ and particularly useful in patients with an attenuated response to infliximab | moderate-to-severe CD. carries same risk as infliximab therefore some screenign and monintoring should be used |
| allopurional inhibits the metabolis of __ | moderate-to-severe CD and may be |
| there is some evidence to support the use of which drugs for the maintaines and remission of crohn's disease with which drugs | azathioprine, mercaptopurine, methotrexate, infliximab, and adalimumab |
| cyclosporine is not recommended for crohn's disease except for patients with symtomatic and severe | perianal or cutaneous fistulas |
| how should dosages be guided with cyclosporine | whole blood concentrations |
| methotrexate given as a weekly injection of 5 to 25 mg has demonstrated efficacy for induction of | remission in crohn's diease as well as for maintenance therapy |
| what are the risks associated with methotrexate | bone marrow suppression, hepatotoxicity and pulmonary toxicity |
| when is adalimumab indicated for crohns disease | those who have lost response to infliximab |
| what is the typically dose of adalimumab | 160 mg SQ folowed by 80 mg SQ at week 2 then subsequent doses of 40 mg SQ every other week thereafter |
| maintenance of remission is more difficult with which disease | crohn's disease than UC |
| which drugs are effective in preventing acute recurrences in quiesent crohn's disease | sulfasalazine and oral mesalamine |
| do steroids play a role in prevention of recurrence of crohn's disease? | NO they have no role and do not not appear to alter the long term course of the diease |
| what are the 4 severity categories of cronh's disease | mild, moderate, sever, fulminant |
| mild to moderate crohn's disease in the ileocolonic or colonic area should receive what a first line treatment | sulfasalazine 3-6 g/day or oral mesalamine 3-4 g/day |
| what drug should a patient receive with mild to moderate crohn's disease of the perianal region | sulfasalazine 3-6 g/day or oral mesalamine 3-4g/day and or metronidazole up to 10-20 mg/kg/day |
| what drug regiemin should be prescribe to a patient with mild to moderate crohn's disease of the small bowel region | oral mesalamine 3-4 g/day or metronidazole |
| what drug regiemin should be given to patient with terminal ileal or ascending colonic disease | budesonide 9mg/day for terminal ileal or ascending colong disease |
| If the patient now has moderate to severe crohn's disease what should be added to the therapy initial (without fistulal) | prednisone 40-60 mg/day |
| If the patient is moderate to severe with refractory and fistulizing disease what should be added to the regemin | infliximab |
| once a person with moderated to severe crohn's disease is stable, you should taper the prednisone over how many weeks | 2-3 weeks |
| if a person who has moderate to severe crohn's disease doesn't get a responce to infliximab what could be added or what can they be switched to | add azathioprine, mercaptopurine, switch to methotrexate oradalimumab |
| if a person presents with severe to fulminant case of crohn's disease what should be added to the regemin | hydrocortisone 100mg by IV q 6-8 hours adn if not response in 7 days cycloporine IV 4mg/kg/day should be initated as last ditch effort before surgery |
| Metronidazole (Flagyl), which also has immunosuppressive properties, is the best studied antibiotic. It is especially effective in patients with | perianal and postoperative CD, with benefits improving as the dosage 10-20 mg/kg/day is increased up to a maximum of 2 g/day. |
| ciprofloxacin (Cipro) in a dosage of 1 g per dayand metronidazole appears to be efficacious in same patients with | perianal disease |
| what the side effects of metronidazole | In addition to a metallic taste, disulfiram-like effect, and gastrointestinal upset, long-term use of metronidazole is known to cause peripheral neuropathy, and patients should be monitored. |
| The salicylates include | mesalamine (Rowasa) and sulfasalazine (Azulfidine). In its various preparations, mesalamine can be released in the stomach, duodenum, ileum, and colon (Pentasa), or primarily in the terminal ileum and colon (Asacol) |
| Common laboratory and radiographic findings of crohn's disease | Mild anemia Mild leukocytosis Elevated erythrocyte sedimentation rate Small bowel involvement Fistulas Strictures |
| Common complaints | Abdominal pain Diarrhea Fever Fatigue Rectal bleeding Weight loss Anorexia Nausea |
| Commonly, patients with Crohn's disease need vitamin and mineral supplementation. Supplementation with | vitamin B12, folic acid, fat soluable vitamins, and calcium should be considered, and periodic checks may be necessary. need to exercise |
| when is budesonide a viable first option for patients | patients with mild to moderate ileal or right side ascending colonic disease. (it is not affective in reaching more distal areas |
| what can be aministered during pregnancy | steroids and sulfasalazine at same dosage but need to give at least 1 mg bid of folic acid |
| how do you treat toxic megacolon. | steroids, cyclosporine and antimicrobials. agressive fluid and elctrolyte management is required for dehydration, ?blood replacement, d/c opiates, anticholonergic these increase colonic dilation |
| what kind of antibiotics should be institude with someone who has toxic megacolon | gram negative bacilli and intestinal anaerobes should be used as preemptive therapy in the event a perforation occurs (2-3 wks) |
| recommended corticosteroid therapy for hydrocortisone, methylprednisolone and corticotropin is | hydrocortisone 100mg q 8 hmethylprednisolone 15mg q 6 hcorticotropin 40 units q 8 h |
| what the systmeic manifestations of IBD | arthritis, anemia, skin manifestion such as erythema nodosum and pyoderm gangrenosum, uveitis, and liver disease |
| while on immunosuppressive agents such as azathiorine adn mercaptopurine what is a monitoring perameter | CBC |
| if the patient presents with blood in the stool, this is a presentation of | ulcerative colitis especially if bright red |
| fever might present with which diease(s) | ulcerative colitis and crohn's |
| arthritis presents in which diease(s) | ulcerative colitis and crohn's disease |
| a person with less than 4 stools per day and blood would have which classification of UC | UC because less than four with and without symptoms |
| ocular involvement is associated with which condition | ulcerative colitis |
| raised red tender nodules | ulcerative colitis |
| hemorrhoids and perirectal abscesses may be present in which | ulcerative colitis |
| which can be associated with decrease hematocrite and hemoglobin | ulcerative colitis |
| which is associated with perianal fistula | crohn'disease |
| which can present with fissures | uc and cd |
| which can cuase hypoalbuminemia | ulcerative colitis` |
| if they have a erythrocyte sedimentaiton rate greater than 30 which ulcerative colitis woud this be classified under | severe |
| tachycardia, anemia, erytrocyte sedimentation reate greater than 30 is which form of UC | sever |
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