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GI Exam 2
Long IBD
| Question | Answer |
|---|---|
| IBD problem is that the _____ _____ is in hyperdrive | immune system (Inflammatory bowel disease) |
| Which of the following medications are associated with QTc prolongation? (Select all) -Ondansetron -Aprepitant -Cimetidine -Prometazine -Droperidol | Ondansetron, Promethazine, Droperidol |
| Inllammatory Bowel Disease is _______ intestinal Inflammation | CHRONIC (they have this disease for the rest of their lives) |
| What are the 2 major forms of IBD? | Ulcerative Colitis and Crohn’s disease |
| Ulcerative colitis is ________ while in Crohn’s disease its _________. *ulcerative colitis is usually limited to the _______. Crohn’s disease this could happen anywhere from _____ to ________ (not limited to the colon) | Continuous; discontinuous; Colon; mouth to anus |
| Depth of inflammation is different, so within the wall of the intestines, Ulcerative colitis will affect a differnt portion of that WALL than Crohn’s disease. Ulcerative colitis is much more prevalent in _____ and Crohn’s disease is more prevalent in ______ | men; women |
| Ulcerative colitis is a much more _______ disease | superficial (only affects the top 3 layers (Mucosa, Submucosa and Muscularis) |
| Crohn’s disease (more common in women) Women are more deep individual thinkers so CD will impact the whole of their _______ | bowel. |
| Etiology of IBD includes: (remember 5 major components) | 1. Immunology; 2. Infection; 3. Genetics, 4. Mental Health, 5. Lifestyle |
| Etiology of IBD: Immunology—> there is a difference in the balance of __-______ and anti-inflammatory markers or cells throughout the immune system | pro-inflammatory *think of it as the strict parent and very fun parent. Strict parent—> much more higher proportion of proinflammatory cells; also have an increase in TNF-alpha ⭐️ and pts will have a decreased antimicrobial activity |
| Etiology of IBD: Infection—> Gut is dirty (lots of bugs in there but there are normal flora and normal organisms; however in IBD—> higher % of __-______ | pro-infammatory bacteria *so not only is the immune system geared towards having more inflammation but your bacteria in your gut also has more inflammation because of the bacteria that are there (*lose of tolerance; altered intestinal barrier that triggers inflammation) *body is constantly trying to attack the normal flora |
| Etiology of IBD: Genetics—> There is a clear correlation between family hx of IBD and they themselves will have IBD. We also uncovered a few genetic markers so for these pts will see—> | increased association in identical twins and first-degree relatives; Clustering in ethnic groups; Immunologic genetic markers |
| Etiology of IBD: Mental Health affects all so here we will see pts with IBD have? | stress, anxiety, depression) which correlate with flares *stressful state and see flare of IBD symptoms |
| Etiology of IBD: Lifestyle factors such as? | Dietary (refined sugars, protein, fats); Smoking (protective and risk-inducing); **NSAIDS, abx, oral contraceptives (increased risk for IBD flare)** *pts that quit smoking—> see an increase in diagnosis of Ulcerative collitis) and opposite is for Crohn’s disease |
| Smoking is protective for a diagnosis of ulcerative colitis but if you quit smoking you will see a rise in ______ but if you smoke its a ____-______ for Crohn’s disease | diagnosis for UC; risk-inducing |
| Diagnosis of IBD is FYI for Dr. Long but ultimately a _______ of the Colin is what’s going to tell us what the problem is | biopsy; *clinically look at s/sx, their stool; look at their colonoscopy results and see if they have any extra colonic manifestations (i.e. other symptoms throughout their body, not in their colon) |
| Which form of IBD is associated with more superficial inflammation? -Constipation-Predominant -Crohn’s disease -Diarrhea-Predominant -Ulcerative Colitis | Ulcerative Colitis |
| Which of the following medications increases the risk for IBD? -Ibuprofen -Acetaminophen -Tramadol -Oxycodone -None of the above | Ibuprofen |
| Which of the following is FALSE regarding Dicylcomine? -It should be used for short-term relief -It is dosed 4x per day -It is CI in hypothyroidism -It can cause drowsiness and blurred vision -None of the above | *It is CI in Hypothyroidism *(its a anti-cholinergic drug, anti=spasmindic athat can be used in both IBS-C and IBS-D; it is CI in hyperthyroidism (remember the list of 4 disease states |
| Presentation of Ulcerative Colitis (UC): the Disease extent is ________. | continuous |
| There are different “varied” options of UC which are? | -Distal (“left-sided” disease which is only the distal colon in the rectum); -extensive disease; -Proctitis (disease is only in the rectum and the rest of the colon is fine); -Prcotostimoditis; -Pancolitis (majority or entirety of the colon like “pandemic” |
| Ulcerative colitis will have these bumps called ______ polyps | pseudo; So in ulcerative colitis we see (mucosal ULCERATION); Ulcer on question equal UC |
| Presentation of UC will be? | mucosal ULCERATIVE colitis, crypt abscesses, and psedopolyps *So remember ulceration and pseudo polyps for UC |
| Signs and Symptoms of Ulcerative Colitis include? | Abd cramping, Frequent, often bloody 🩸, stools, weight loss, fever and tachycardia (if severe), Blurred vision, ocular pain, photophobia, Arthritis, *1-3 cm raised, erythematous, and tender nodules *blood means ulcerative Colitis |
| Mild Ulcerative colitis Clinical presentation is? | < 4 stools/day; no systemic disturbance; normal ESR |
| Moderate UC Clinical presentation is? | >4 stools/day; minimal systemic disturbance |
| Severe UC Clinical presentation is? | > 6 stools/day with blood; increased HR, decreased BP, anemia, low albumin, fever, increased WBC, ESR> 30 mm/hr |
| Fulminant UC Clinical Presentation is? | > 10 stools/day + CONTINUOUS BLEEDING; abd tenderness, transfusion requirement; Colonic dilation |
| Blood in stool means UC. If they have CONTINUOUS bleeding coming out of their rectum its ______ | severe |
| If pt has NO systemic signs (no fever, no elevated WBC count, ESR is normal (remember ESR is a sign of inflammation), low amount of stools per day? | We’re not as worried, its obviously mild |
| If they come in and have a fever? Could it be constipation diarrhea, IBS is not all there is, you refer these pts since its a sign of ______ | infection |
| Clinical Presentation of UC: On a physical exam we will see _________, anal fissures, perirectal abscesses as well as? | ⭐️ HEMORRHOIDS; *iritis, uveitis, episcleritis, conjunctivitis (if ocular involvement) |
| Cummulative: Where else can we see Hemmhorids? | Constipation (because they are strain which forms the swollen blood vessels *So constipation and UC have hemmorhoids |
| Clinical Presentation of UC: For lab tests we will see ⬇️ HgB and Hct, why? | Because their bleeding; *we will also see ⬆️ ESR or CRP (signs of inflammation); ⬆️ WBC (immune system is fighting an infection) |
| What are the Complications of Ulcerative Colitis? | Hemorrhoids; Colonic Hemorrhage; Colonic dysplasia (colon cancer); ⭐️ TOXIC MEGACOLON (colonic distension +/- perforation, acute colitis, SYSTEMIC toxicity *avoid antimotility agents ⭐️ |
| MUST KNOW: Toxic mega colon is the most ________ complication of UC | FATAL *this is when the immune system attacks the colon so strongly that it leads to systemic toxicity throughout the whole body and they have a very high likelihood of DEATH |
| For pts with UC, there is a high risk of pts getting a toxic megacolon if they take ____-_______ agents | anti-motility (i.e. Loperamide (Imodium) |
| Dr. Long possible question: So if I give you an UC pt that is coming in and saying they are having diarrhea, are you going to give them Loperamide? | NO, because it could increase their risk of something fatal/deadly |
| Which of the following is NOT an appropriate treatment for hemorrhoids? -Docusate capsules -Phenylephrine suppositories -Witch Hazel pads -Benzocaine cream | *Phenylephrine suppositories; *Caveat of phenyleprine suppositories is? You cant use it internally (don’t want it systemic b/c its a vasoconstrictor) Suppositories are a no-go for phenyeprhine since even suppositories can be absorbed internally; We would want phenylephrine cream (something that is PURELY topical) -Docusate (prevent additional straining) |
| Presentation of Crohn’s Disease: remember its ________ | discontinuous -patches all over the place |
| If we were to do a colonoscopy for Crohn’s disease we would see a classic sign called? | cobblestoning (Paths) |
| A Classic symptoms that we MUST KNOW for Crohn’s disease is the word ______ | FISTULAS *other presentation to remember for CD are STRICTURES |
| Definition of a FISTULA is? | (Its a connection between 2 structures in the body and see a “pathway”(remember the depth of inflammation, it’s ALL LAYERS of the bowel wall; so it makes sense that we see a fistula form through all layers of the bowel |
| Strictures are? | (bowel wall getting inflammed, the hole in which things travel through gets small and tight and may get blockages) |
| Clinical Presentation of CD: Mild to moderate is? | ambulatory, No systemic disturbance, No dehydration or weight loss, No abd tenderness/mass/obstruction |
| Clinical Presentation of CD: Moderate to Severe is? | Mild-mod treatment failure OR fever, weight loss, or anemia, Abd pain/tnderness, Vomiting, intestinal obstruction |
| Clinical Presentation of CD: Severe to Fulminant is? | Persistant symptoms OR systemic toxicity despite steroid/biologic treatment OR Cachexia, abscess, intestinal obstruction, or rebound tenderness |
| Other s/sx of CD inlcude? | abd pain, frequent bowel movements, WEIGHT LOSS and MALNUTRITION, fever and malaise, arthritis |
| Long: remember severe and fulminant are systemic signs like fever and weight loss. For Crohn’s disease the BIG THINGS to worry about are? Why? | WEIGHT LOSS and nutritional deficiencies or MALNUTRITON; B/c the entire wall of the bowel is diseased and therefore your really not absorbing nutrients or anything else. |
| So these pts are excreting things they should otherwise be absorbing, but bc you have all of these different pockets of disease that goes through the entire length of the wall of the colon, they can’t absorb things and they get ______ | malnourished |
| If your given a pt presentation how can you decide that this pt has Crohn’s disease? Your going to see—> But what is not listed here that WAS listed for UC? | -⬆️ WBC count, ⬆️ ESR or CRP (those inflammatory markers); -A ⬇️ in Hgb *when we see bleeding, we’re thinking UC not CD |
| We don’t see a drop in Hgb in Crohn’s disease because we don’t see? | bleeding 🩸 |
| So for complications of CD we are going to remember _________ and ________ | Malabsorption and Fistulas *will also see Growth failure (pediatrics) |
| Pediatric pt that is having nutrtional deficiencies throughout the time at which they’re growing up, your going to see _______ _______ | Growth failure (not going to grow as well if they aren’t able to absorb the vitamins |
| Which of the following medications increases the risk for malabsorption or nutritional deficiencies? -Loperamide (slows it down, prevents things from coming out) ⬆️ absorption -Bisacodyl (stimulant: push the stool out faster) -Mineral Oil (Lubricant: coat the stool and prevent absorption) -All of the above -Bisacodyl and mineral oil | *Bisacodyl and Mineral oil *remember we talked about the stool moving through the colon and as its moving through the colon, things are getting absorbed (water and nutrients), so what we think about here is what’s going to push that stool out faster or what is going to block the absorption from happening |
| For these UC and CD pts with IBD, they will have what is called ______ ________. Meaning that it affects other symptoms of the body | Extraintestinal Complications (*not only do they ahve to worry about all these GI issues, they also can have liver, eye, blood, bone, and skin issues) Systemic problem because the problem is the Immune system. |
| Hepatobiliary complications seen with UC would be? | Primary sclerosing cholangitis |
| Cholelithiasis (gall bladder stones) would be seen with? | Crohn’s disease |
| We see arthritis and ocular complications with ____ UC and CD | both |
| Skin lesions and skin issues tends to be more related to? | Crohn’s disease (All will tend to come out with flares, so if you have more severe/fulminant disease will have these: *Erythema nodosum, Pyoderma gangrenous, Aphthous ulceration, Sweet’s syndrome |
| Which of the following is NOT a complication of ulcerative colitis? -Toxic megacolon -Colonic dysplasia -Hemorrhoids, anal fissures, and perirectal abscesses -Nutritional deficiencies | Nutritional deficiencies (more prevalent in CD) |
| Which of the following is NOT true about complications of Crohn’s Disease? -Malabsorption can result in nutritional deficiencies -Colonic hemorrhages are more severe than in UC -Perianal fistulas can develop -Pediatric pts may suffer from growth failure | Colonic hemorrhages are more severe than in UC *blood = UC |
| General approach to IBD: So overall IBD—> we need to treat the active disease which is called ______ then maintain disease remission. We will also add ______ therapies. We can consider surgical procedures if necessary (insufficient control with medications; medications dose requirements—> AEs; We can also try NUTRTIONAL SUPPORT (CD) | -induction (shut down the immune system) -Adjunctive (side-kicks, help out but aren’t main player) |
| We can consider surgical procedures if necessary but could this be considered in CD? | -Yes? Is it effective No bc CD is discontinuous, that means not only would you have to have just one surgical incision on the bowel, would need many and get lots of scar tissue (medication dose requirements—> AEs; Surgery? Think UC |
| Who will need TPN (nutritional support)? | CD patients who can’t absorb nutrients from the intestines themselves |
| General approach medications (listed from slide) are? | amniosalicylates, corticosteroids, immunosuppressives, biologic agents, antimicrobials |
| Important to remember that NONE of our pharmacologic Therapy agents _____ the disease | CURE *IBD forever |
| Our primary therapy for IBD are the ______ *gold standard/first line | aminosalicylates (Sulfasalazine/Mesalamine) *this is what we will try for pts with mild/moderate disease *Old is Sulfasalazine but Claim-To-Fame option for IBD is Mesalamine |
| Pt comes in, they have mild IBD, what is the option? | Mesalamine *unless there is some reason they can’t take it |
| Sulfasalazine is a very old drug, but cheap. This is a combination of ______ + ______ | Sulfapyridine + Mesalamine *mesalamine is the active component of Sulfasalazine, however this drug has a sulfpyridine attached to it that ends up getting absorbed in the body, causes some issues, and then they excrete it in the urine |
| Sulfasalazine has better efficacy in _____ ____ but you would use it for BOTH | ulcerative colitis |
| Sulfasalazine is way cheaper, however it has that sulfa component in it which plays NO ACTIVE ROLE of the drug but it does cause ______ ____ responses. This drug should ALWAYS be given with ____ _____ supplementation to prevent the side effects | sulfa allergy; Folic Acid |
| Remember 1st line is ________ for IBD induction and maintenance therapy and comes in many formulations. It is rapidly and completely absorbed in small intestine, but poorly/ NOT absorbed in the ______ | Mesalamine; Colon |
| Have to decide who am i going to deliverMesalamine to the part of the colon that is the problem? We would use something topical over oral if we can. If you try oral first and its not effective, you can do both: A _____ tablet + an _____ in the setting of a flare | Pentasa tablet + an enema |
| One Achilles heal for Mesalamine is that you should not recommend it for pts that have _____ or _____ problems (i.e. CKD, cirrhosis) | Renal or Hepatic |
| Know which formulations of Mesalamine are suppositories and enemas: Suppository form is? Enema form is? | Canasa Rowasa *Rowasha sounds like “you wash with water” —> (Enema) |
| ER capsule formulations of Mesalamine are? | Pentasa and Apriso |
| Corticosteroids are used mainly for IBD ______ therapy. they suppress _____ inflammation | induction; acute ⭐️ Steroids are ONLY for Induction of IBD |
| Pt comes in, newly diagnosed, system is going crazy and need to shut it down quick, we give them? Or pt is on Mesalamine and they forget to take their pills this weekend when they went on vacation and now they’re coming in with a big flare, we need to stop it quickly, we give them? | High dose steroids to suppress that acute inflammation; Steroids |
| We get lots of SE from steroids which is why we don’t use them for IBD maintenance for long-term at high dose. What are our steroid agents and their Equivalent PO dose (mg)? | Prednisone (5); Prednisolone (5); Methylprednisolone (4); Hydrocortisone (20); Dexamethasone (0.75) |
| Pt comes in and has a flare, we would give them Methyprednisolone (IV) and if you want to switch it to a equivalent dose orally should be able to using the _____ | ratios P—> 5 Meth-> 4 Hydro—> 20 Dex—> 0.75 |
| Immunosuppressive agents: the one that’s studied the most in IBD is ________. Other is mercaptapurine (Purinethol). These are used long-term, ________ tx of UC and CD. | Azathioprine (Imuran); maintenance; Mesalamine |
| Why would we use Azathioprine (Imuran) or mercaptapurine (Purinethols) together with another agent such as a 5-ASA/Corticosteroids, and TNF-a antagonists? | B/c it takes a very long time to see the effect of it (weeks to months), so someone comes with a flare, *give them steroids to induce, drop the immune system, and start the Azathioprine so that when the steroids are off, we still see SE of Azathioprine holding the imme system down |
| So we give Azathioprine or mercaptapurine with other agents because it takes _____ to _____ before noticeable benefits are observed | weeks to months |
| Main AE to know for Azathioprine or mercaptapurine is? | *bone marrow suppression (blood count goes down) *others are infection, pancreatitis, hepatitis, and increased risk of lymphoma with long-term use |
| Mentioned by Spears, _________ is an interaction with Azathioprine | Allopurinol *NAPLEX question Allopurinol inhibits Xanthine Oxidase which is what breaks down azathioprine, so if you take it with your gout medication, your going to cause Azathioprine to increase in conc., causing blood counts to go down even further |
| Methotrexate (PINK for CD), really no evidence for being used in UC so don’t recommend. YOU DO NOT WANT TO GIVE IT AS __________ FOR INDUCTION | monotherapy *cannot give it alone *avoid monotherapy for induction |
| Methotrexate can be given ____ once a week as well as SQ once a week and just like Sulfasalazine you give it with ______ ______. SE to know for MTX are? | IM; folic acid *very toxic medication, its a cause of End stage liver disease, very hepatotoxic, make pts get allopecia (hair loss) and can drop your blood counts (Bone marrow suppression); TERATOGENIC |
| High level of teratogenicity with MTX, for women of child-bearing age, must communicate that she needs to be on? | a form of birth control because there’s a high level of teratogenicity |
| Calcineurin inhibitors: Which one is used most in transplant? Tacrolimus (Prograf), however in IBD the one that we really see is _______. It is used for ____-____ benefit in tx of acute, severe UC | Cyclosporin (Neoral); short-term *Blue for UC |
| Scenario: Pt with UC, and your tracing the usual tx, big dose of steroids and nothing really happens, they are having poor SE of IBD and flare is not controlled and physician is saying, “is there anything else we can try before we take the colon out?” | Cyclosporin (neoral) but remember it’s nowhere near our 1st line. *used to avoid colectomy in steroid failures (NOT 1st line) |
| AE seen with our CNIs (Calcineurin inhibitor Cyclosporine (Neoral) is: | Infections, NEPHROTOXICITY, hypertension, electrolyte imbalances, neurotoxicity |
| Our Aminosalicyclate medications are? | Sulfasalazine and Mesalamine |
| Our immunosuppressive agents are? | Azathiprine, Mercaptopurine, Cyclosporine, and Methotrexate |
| Our Biological agents are: | Infliximab, Adalimumab, Certolizuman, Golumumab, Vedolizuman, Natalizumab, Usetkinumab, Guselkumab, Risakizumab, Ozanimod, Etrasimod, Tofactinib, Upadacitinib |
| Infliximab (this drug is written in white) why? | becasue of the biologics (your more potent agents) this is your #1. First line if they have moderate to severe disease |
| Pt comes in, and Dr. Long says they have severe disease, guidelines say to start with ________. If its mild, remember start with _______ | Infliximab (Remicade); Mesalamine |
| Infliximab (Remicade) is a IgG1 _______ antibody (ends in mab). This can be used for both induction and _______ for both CD and UC and mainly in mod-severe pts. | monoclonal; maintenance |
| If a pt has hx of heart failure or seizure disorder, you would not use _______. What is the boxed warnings? | Infliximab (Remicade); Infections, malignancy, TB |
| Infliximab “with an I” is given _____ every 8 weeks. We will give the pt __ months or 12 weeks to see if they have a sufficient response to Remicade. If they dont, and symptoms of OBD has not been resolved, we _______ and say it doesn’t work | IV; 3 months; discontinue |
| Because Infliximab (Remicade) has that chimeric component, we need to __-_____ to prevent symptoms or SE of the drug during the infusion | pre-medicate (*Tylenol, Benadryl and steroids) *give it immediately before starting the infusion (30 min before) |
| Your other options for TNF-a blockade: main one for both CD and UC is ______. It’s not as effective as Infliximab (Remicade). Considered one of the weakest in the biologics but still has a box warning for? | Adalimumab (Humira); infections and LYMPHOMA |
| We would only use ______ if they lost response to Infliximab (Remicade), *i.e. give those first couple of doses and move to every 8 weeks, now we can consider this medication. | Adalimumab (Humira) |
| Aside from Humira, we could also consider _______ or ________. But one is for CD and the other is for UC. | Cymzia (certolizumab) (*CD) or Simponi ( golimumab) (UC) |
| In clinical trials this drug was no better than placebo and therefore we don’t recommend which biologic? | Cimzia (Certolizumab) ⭐️ this will never be the answer choice |
| Vedolizumab (_______) is used in moderate-severe CD and UC and ONLY use if unresponsive to TNF-a inhibitors or unresponsive/dependent on corticosteroids | Entyvio |
| Vedolizumab (Entyvio) is given ___. If they do ok with the infusions, we can opt to give them SQ so this is a new FDA approval meaning pts can take it at home after 2 infusions and switch to SQ every other week | IV *MUST ALWAYS START IV with Entyvio |
| We will discontinue Vedolizumab (Entyvio) if there is no benefit by week __. With this agent, we ________ with other immunosuppressants and TNF-a inhibitiors | 14; AVOID (it is strong enough on its own for induction and maintenance) |
| VERY BIG WARNING: There is a risk for ______ ______ _______ (aka PML) with Vedolizumab (Entyvio). It can also hurt the liver (hepatotoxic) | progressive multifocal leukoencephalopathy *drug gets to brain—> puts pts at high risk of a virus that targets the white matter of the brain and they die) |
| (Spears told us not to know this drug but Long does)—> This med is seen as last-line for our CD pts. We would use this med if pts are UNRESPONSIVE to all the other options (corticosteroids/TNF-a) | Natalizumab (Tysabri) (Pink so for CD) |
| Just like with Infliximab, we discontinue Natalizumab if no benefit seen by week ___. We avoid with immunosuppressants and TNF-a (use alone) and we see a REMS warning: risk of _____ | 12 or 3 months; PML *Difference for this PML compared to Vedolizumab (Entyvio) is that it comes with REMS so a “higher level” or more likely to occur.” We also see hepatoxicity |
| Ustekinumab (Stelara) is white so for BOTH UC and CD. It’s used in ____-_____ CD and UC. Unique characteristic about this drug is that the first single IV dose is _____-_______ (math). And once they get that first initial infusion to induce their immune system being depressed, the maintance can be ____ | moderate-severe; weight-based; SQ |
| Package insert for Ustekinumab (Stelara) state that this drug as well as in teh guidelines that if having insufficient benefit, then we can _______ dosing interval | decrease *if i decrease the dosing interval (time b/w each dose, we give? More drug more frequently |
| FDA places a big emphasis to ______ ______ ________ with Ustekinumab (Stelara) but really for all immunosuppressant drugs | AVOID LIVE VACCINES |
| As of right now (LIVING guidelines FDA document that is constantly updated), IL-23 inhibitor biologic ages are only recommended for _____. But _______ and ______ BOTH have FDA approval CDs | UC (ulcerative collitis); Risankizumab (Skyrizi) and Mirikizumab (Omvoh) *Skyrizi and Omvoh—> FDA approval for both CD and UC but Omvoh is less potent *Exam purposes—> Ulcerative Colitis |
| The IL-23 inhibitions (Guseklumab (Tremfya), Risakinzumab (Syrizi), and Mirikizumab (Omvoh) are used in moderate to severe UC and are monthly ___ induction infusions for 3 months and can be switched to _____ maintenance dose. | IV; SQ *use lowest effective dose |
| What risk do the IL-23 inhibitors carry? | risk of infection (URTIs, TB), malignancies, and NEUTRALIZING ANTIBODIES ⭐️ (Cause the formation of antibodies that will then attack the drug) |
| Sphingosine 1- phosphate (S1P) receptor MODulators are used in ______-_____ UC and all end in “MOD” | moderate-severe |
| Your S1P modulator agents are? What’s unique about them is that they are daily ____ dosing | Ozanimod (Zeposia); Etrasimod (Vesipity); PO; *hepatic dose adjustment with (Ozanimod); screen for TB and varicella zoster virus antibodies prior to initiation |
| Special thing to remember about S1P modulators is that _______ has increased exposure in poor metabolizers of CYP2C9 | Velsipity (Etrasimod) *leads to increased exposure and too much toxicity; rapid metabolizers (ineffective) |
| If a pt is a strong INDUCER/INHIBITORS of 2C8 and QTc prolonging agents, you should not use the ____ _____ (FQ, droperinone, Zofran, etc) | S1P modulators |
| S1P inhibitors also have a unique AE in that they can cause: | macular edema (swelling in the eyes), and can also cause liver dysfunction, dyspnea, sink cancer, bradycardia, PML, PRES (form of encephalopathy) |
| Aside from the Strong CYP 2C8 inducers/inhibitors, avoid use of S1P inhibitors with—> | immunosuppressants or active infections, pts with recent hx of MI, stroke, TIA, HF, Severe sleep apnea, or hepatic impairment; avoid LIVE vaccines, avoid in pregnancy |
| JAK (Janus Kinase) enzyme inhibitors are used in moderate to severe ____ IF UNRESPONSIVE to TNF-a inhibtiors. | UC *know that access is restricted to specialty pharmacies; be sure to use lowest effective dose; requires renal and hepatic dose adjustments; may increase cholesterol levels |
| The risk that comes with JAK inhibitors includes? | Infections, malignancies, major adverse CV events, thrombosis (clotting) & treatment-related mortality |
| JAK inhibitor Caution use with: | Hepatic, renal, or pulmonary impairment; Age >/= 50 + CV risk factor, especially if past/present smoker |
| Avoid use of JAK inhibitors with? | immunosuppressants or biologic DMARDs; with CYP3A4 inducers; with ANC , 1000 cells/mm^3 or Hgb < 9 g/dL; in pregnancy; with active or latent infection (i.e. TB, hepatitis B, herpes zoster) |
| Options for JAK inhibitors are? | Tofacitinib (Xeljanz) and Upadacitinib (Rinvoq) *oral and liquid |
| If a pt has ASIAN descent, you cannot use which JAK inhibitor? *Example: AB is an Asian American pt…. | Tofacitinib (Xeljanz) |
| Tofacitinib (Xeljanz) key facts to know: Comes as an ____ formulation (IR/ER tab and liquid); Discontinue if insufficient benefit by week ____. Additional caution: _____ _____ | Oral; 16; Asian descent |
| Upadacitinib (Rinvoq) Key facts to know: Comes as an _____ formulation (ER tab and liquid); Discontinune if insufficient benefit with ___ maintenance dose; Has an additional indication for ____ | Oral; 2x; CD |
| Which medication is NOT used for UC? (Pink drug) -Remicade -Tysabri -Humira (both) -Imuran (both) | Natalizumab (Tysabri) *last line for CD |
| Which medication is correctly matched to its brand? -Vedolizumab- Stelara -Tofacitinib- Trulance -Infliximab- Remicade -Natalizumab- Xeljanz | infliximab-Remicade |
| Which of the following is the best option for a 55 yo smoker w/ a hx of MI and UC? -Upadacitinib -Tofacitinib -Ozanimod -Guselkumab -None of the above | Guselkumab *are their any not for UC? Any can i eliminate? Heart issue? Smoker? |
| Treatment approach (Timing):Remember that Steroids and Cyclosporine are for ______ _______ | Induction only |
| Treatment approach (Timing): Mesalamine, MTX, and Biologics can be used for both ______ ________ treatment | Induction and Maintenance *effective bullies |
| Treatment Approach (Timing): Thiopurines can only be used for _________ treatment | Maintenance *remember they take forever to work (weeks to months) |
| Treatment Approach (Severity): Mild to moderate we give? | Mesalamine |
| Person comes in and is severe, you would not start with Mesalamine, your going to start with _______, MTX, Cyclosporine. Which biologic do we start with? | Biologics; Infliximab (Remicade) |
| UC Algorithim of Biologics: Biologic Naive (never had any kind of biologic before for UC but they are more severe-moderate, you would start with? | Infliximab then work you way down the treatment pyramid; Adalimumab (Humira) is considered lower efficacy than the other drugs so that is last line. But if you had someone that didn’t meet the criteria for all others, then you could pick Humira |
| UC Algorithim: Someone that is experienced (moderate to severe, they took Infliximab before and now its not working or they had a SE to it you would switch based on category—> | (Ustekinumab, Upadacitinib, Tofacitinib)—> (Guselkumab, Risakizumab, Mirikizumab)—> (Adalimumab, Vedolizumab, Ozanimod, Etrasimod) |
| How Dr. Long will ask us on the exam about the UC algorithm—> “Infliximab is ____ for severe. ______ is first for mild. | First; Mesalamine *”A pt with …. Whatever characteristics can get which drug?” Or which of the following can they not have as an option? CI, warnings or AVOID |
| CD algorithm: First is _________ and last is _________ | Infliximab; Natalizumab |
| Mild to moderate UC: Daily _______ is first line. Add enema/suppository if left-sided/extensive disease (proctosigmoiditis/proctitis); Use high dose 5-ASA (>3g/d) with enema if suboptimal response. | Mesalamine *left-sided diseases (at the end) give enema or suppository that works in the end; ⬆️ dose, *no steroids long term |
| Mesalamine for mild-moderate UC: If refractory to optimized PO and rectal 5-ASA, can add ___ _____ or budesonide | PO Prednisone *Avoid corticosteroids for remission maintenance (withdraw within 2-4 weeks) |
| Moderate-Severe UC: You start with Infliximab. But if you had a pt that was high risk or had cancer and the provider states: “I really don’t want to give them Infliximab,” could you give Mesalamine? | You could but it won’t be the most effective. |
| Moderate-Severe UC: Early use of biologics is preferred to step-up strategy after 5-ASA failure in mod-severe UC. If naive and mod-severe, use Infliximab for ________. Use _______ inhibitors or usetinumab for induction if fail TNF-a | Induction; JAK *Avoid azathioprine for induction because its ONLY MAINTENANCE |
| CD induction of remission—> Give _____ if unresponsive to 5-ASA. Avoid using MTX _______ due to lack of data for efficacy inducing remission alone. What other drug do we AVOID using monotherapy? *due to delayed onset—> use together with Corticosteroid or TNF-a. What drug is at the end of CD tx? | Corticosteroids; monotherapy; Thioprine; Natalizumab (Tysabri) |
| CD maintenance of Remission—> AVOID corticosterioids long-term use. Withdraw in __-__ weeks. If moderately severe, fail 5-ASA, or steroid failure/dependence use: ______, _______, or ______. If fail Azathioprine—> switch to TNF-a inhibitors or _________ | 2-4; thiopurine, MTX, or TNF-a inhibitor; Natalizumab *Azathioprine usually preferred vs methotrexate. |
| Which of the following agents used for IBD can be given SQ? -Natalizumab (IV) -Adalimumab -Tofacitinib (oral) -Etrasimod (oral) | Adalimumab |
| Antimicrobial agents are the ___-_____, not the hero of the story. They are not going to stop the flare but may be used to lessen the incidences of flares by helping with what etiology of IBD? | side-kicks; Infection (*where we have more pro-inflammatory bacteria) |
| The 2 antibiotics that we would use together for _________ therapy are _______ and _______. *Giving abx long-term induces resistance | ADJUNCTIVE; Ciprofloxacin and Metronidazole |
| What is the BEST description of metronidazole’s spectrum of activity? -Gram + -Gram - -Anaerobe -Atypicals | Anaerobe |
| Which of the following groups of organisms does Ciprofloxacin cover BEST? -Gram + -Gram - Anaerobe -Atypicals | Gram - |
| Additional Adjuvant Therapy: we really would use surgery for UC becuase it’s a ______ disease progression. For CD we will use _______ ________ who have “deep issues.” We will not give Loperamide to what kind of patients: ____ because of a risk of _____ _______ | Continuous; nutritional support; UC; toxic megacolon *other agents for pain relief, diarrhea control, Vitamin D and calcium for osteoporosis and Vit B12 and iron supplementation for malabsorption |
| UC complications for pts that get a colectomy are? | Colonic perforations, TOXIC MEGACOLON, Uncontrolled Hemorrhage, colonic stricture |
| Proctocolectomy (remove the piece of the colon that is the problem) can lead to UC curative. Can we do the same for CD? When multiple resections are cut in CD it is known as _____ _____ _______ | No, would require multiple resections because it’s discontinuous. *everytime you cut it leads to malabsorption of meds, food, vitamins) -Short Bowel Syndrome (issue with short gut is malabsorption) |
| Nutrtional support for CD—> we will tell our CD pts to eliminate exacerbating foods if applicable and tell them to keep a diary and tell us when the flares are occurring and can help determine if its related to: | Lactose? certain types of foods? |
| Nutrtional Support: Enteral nutrition—> ⬇️ inflammation and intestinal cytokine production. Parenteral nutrition is reserved for? What are the Enteral CI? | Severe malnutrition and Enteral therapy failure/CI; -Perforation, Protracted vomiting/Short bowel syndrome, Severe intestinal stenosis. |
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