Lewis IBD Drugs

Sulfasalazine ADR

anemia, hepatotoxic, nephritis, thrombocytopenia, yellowing of skin/urine

Which medication can reduce sperm counts in men

SSZ

Which medication should be used with cautionin G6PD deficiency

SSZ

Which medication decreases folate levels

SSZ

Which medications should be avoided in sulfa allergy

SSZ, mesalamine, balsalazide

Which medication should be avoided in PKU

apriso/mesalamine

Which formulation of mesalamine is topical

rowasa (enema) canasa (suppository)

List 5-ASA

SSZ, mesalamine, balsalazide

Indication of 5-ASA

UC > CD, can be used in mild CD

Indication of CCS

does not maintain IBD only for suppressing inflammation

Which CCS is used in IBD

budesonide

List immunomodulators

AZA, 6-MP, MTX, cyclosporine

Indication for AZA or 6-MP

not for induction unless in combo with TNFa, can be used for maintenance

Indication of MTX

can be used for induction (last line) and maintenance (not first line)

Indication fo cyclosporine

can be used for induction for UC, and maintenance for UC and CD if no other options

Immunomodulators ADR

bone marrow suppression, pancreatitis

immunomodulator therapy: BBW and general notes

BBW malignancy, check TPMT activity, no live vaccines

DDI with immunomodulators

Xanthene oxidase inhibitors increase toxicity, reduce 6-MP by 25% if used with allopurinol, febuxostat is CI

Cyclosporine BBW

increase risk of infection, lymphoma

Cyclosporine notes

brands are not interchangeables, DDI with all statins NTE 10 mg atorvastatin or 5 mg rosuvastatin

When would u use antibiotics

adjunct or preemptive for perforation

Which antibiotics can you use

metronidazole and cipro or rifamycin

What is used first line for induction and maintenance

TNFa inhibitors, vedolizumab (entyvio)

Which TNFa inhibitors are ONLY used for UC

golimumab (simponi)

Which TNFa inhibitors are ONLY used for CD

certolizumab (Cimzia)

Which TNFa inhibitor can be used for UC and CD

infliximab (remicade) + adalimumab (humira)

Infliximab monitoring

BP/HR during infusion until normal

TNFa inhibitors ADR

malignancy, worsening HF or anemia,

TNFa inhibitors BBW

inc risk of infection and lymphoma

Recommendation for IBD in patients > 60

TNFa monotherapy preferred, if severe then use TNFa + thiopurine for induction then d/c thiopurine 12-24 mo after therapy

Recommendation for IBD in young male patients

TNFa + MTX for induction > TNFa + thiopurine for induction then d/c thiopurine 12-24 mo after therapy

What should you do before d/c thiopurine

perform colonoscopy to confirm mucosal healing and obtain TNFa-i troughs

If a patient has loss of response to TNFa and they have low drug levels and positive anti drug antibodies what should you do

switch alt TNFa-inhibitor

If a patient has loss of response to TNFa and they have low drug levels with negative anti-drug antibodies what should you do

due to PK failures = inc dose or shorten interval

If a patient has loss of response to TNFa and has normal drug levels and negative drug-antibodies what should you do

due to PD failures = switch to another class

List anti-integrins

vedolizumab (entyvio) natalizumab (tysabri)

Which anti integrin is gut selective

vedolizumab entyvio

Natalizumab indication

moderate-severe CD

Adr for anti integrins

risk of PML, infection, hepatotoxicity (rare)

Notes for duration of anti integrin therapy

d/c if no response after 12-14 weeks

Monitoring for natalizumab

negative JC virus antibody q 6 mo

Anti interleukins indication

not first line

Which anti interleukins can be used for both CD and UC

ustekinumab, risankizumab, mirlizumab

Guselkumab indication

UC only

Interleukin antagonist ADR

RPLS (rare: ustekinumab, guselkumab), hepatotoxic, anemia, infection

List Janus kinase inhibitor

tofacitinib (xeljanz) upadacitinub (rinvoq)

What should you check before initiating a janus kinase inhibitor

absolute lymphocyte ≥500, ANC ≥1000 Hgb ≥9 (tofacitinib) ≥8 (upadacitinib)

Monitoring for janus kinase inhibitors

hepatitis + TB screening, CBC/LFT, lipids

ADR for janus kinase inhibitors

thrombosis, MACE, malignancy, hepatotoxicity

Concern for antibody development with janus kinase inhibitors

none

what is a dose dependent risk for janus kinase inhibitors

herpes zoster → give shingrix

List S1P modulators

ozanimod (zeposia) etrasimod (velsipity)

Which medications have risk for antibody development

TNFa inhibitors, IL antagonists

Zeposia DDI

MAO-I use, untreated sleep apnea

S1P antagonist CI

prior CV event (6 mo), HF, pacemaker

What can u use for induction of CD

• steroids +/- thiopurine or MTX

• TNFa-i +/- thiopurine

• anti integrins

• IL antagonists

What can you use for induction of UC

• 5-ASA +/- steroids or thiopurine

• TNFa-i +/- thiopurine

• vedolizumab (entyvio)

• janus kinas inhibiors

• il- antagonists

• S1p antagonists

• IV cyclosporine LAST LINE

What agents can you use for maintenance in MILD UC

mesalamine

What agents can you use for maintenance in moderate-severe UC

everything NOT natalizumab

What agents can you use for maintenance for mild CD

budesonide then change to thiopurine/MTX or 5-ASA

What agents can you use for maintenance of moderate-severe CD

TNFa-i, integrin antagonists, thiopurine, MTX, IL- inhibitors, upadacitinub

General recommendation for mild disease

step up

General recommendation for therapy approach for moderate-severe disease

top down