IBD- Madras - Exam 3

What part of the body is effected by UC?

What part of the body is effected by UC?

colon/ large intestine and rectum

What is the triad of symptoms when it comes to UC?

1. abdominal pain

2. bloody diarrhea

3. rectal bleeding

What are the 4 presentations of UC? (include stools/day and whether or not they have systemic effects)

1. mild- NO SYSTEMIC disturbances, <4 stools/day

2. moderate- MINIMAL SYSTEMIC disturbances, >4 stools/day

3. severe- SYSTEMIC disturbances, >6 stools/day

4. fulminant- >10 stools/ day with continuous bleeding

If below the splenic flexure, the UC is ______________.

distal/left-sided

If above the splenic flexure, the UC is ______________.

extensive

The proximal colon refers to the…

cecum, ascending colon, and transverse colon

Proctitis is inflammation of the _________.

rectum

Topical therapy like suppositories and enemas are for distal or extensive UC?

distal

PRACTICE:

Imaging was done and the images shows continuous lesions from the transverse colon, down to the rectum. This UC would be classified as distal or extensive?

EXTENSIVE because it’s above the splenic flexure

Answer the following about Sulfasalazine:

• brand name

• dosage form (oral, infusion, etc.)

• site of action

• active moiety

• Azulfidine

• oral

• colon (distal+proximal)

• 5-ASA

What are the ADRs and monitoring parameters for Sulfasalazine?

ADRs: DECREASE FOLATE ABSORPTION, G6PD Deficiency

Monitor: CBCs, LFTs, SCr, BUN

What syndrome can be caused by an allergic reaction to sulfa meds like Sulfasalazine?

Steven-Johnson Syndrome

Oral mesalamine is used for _______________ UC. Topical mesalamine is used for __________________ UC.

extensive, distal

Answer the following about each brand name of Mesalamine:

• Canasa is what dosage form and what SOA?

• Rowasa is what dosage form and what SOA?

• Pentasa is what dosage form and what SOA?

• Olsalazine has what ADR?

• Canasa—> suppository—> rectum (for proctitis)

• Rowasa—> enema—> distal

• Pentasa—> capsule—> extensive

• Olsalazine can cause diarrhea.

When are oral steroids used in UC?

NOT FOR MAINTENANCE THERAPY—> ONLY TO INDUCE REMISSION THEN TAPER OFF

Answer the following about Azathioprine and 6-mercaptopurine:

• brand names

• indication

• monitoring

• Imuran, 6-MP

• NOT FOR MONOTHERAPY for tx, used to maintain remission

• monitoring-CBC, SCr, BUN, LFTs

Genetic testing should be done to reduce thiopurine toxicity from azathioprine and 6-MP because of what enzyme and what metabolizer?

NUDT15 and TPMT

What drugs used in IBD are TNF-blockers? Are they used in UC, Crohn’s, or both?

1. Inflixamab- both

2. Inflixamab-dyyb- both

3. Adalimumab- both

4. Golimumab- ONLY IN UC

Answer the following about INFLIXIMAB:

• brand name

• INDICATION

• live vaccines?

• dosage form

• monitoring

• C/I

• Remicade

• for moderate/severe UC or Crohn’s inadequate to other therapies

• NO LIVE VACCINES

• IV INFUSION

• Monitoring: CBC, CMC, LFTs, TB, Chest xray, Hep B and C

• C/I: doses >5 mg/kg contraindicated in HF Class III and IV

What are some live vaccines?

• intranasal influenza

• varicella

• measles, mumps, rubella-MMR

How is Infliximab (Remicade) different from Infliximab-dyyb (Zymfentra)?

DOSAGE FORM and INDICATION !!!!!!!!!!!!!

• Infliximab is an IV infusion and Infliximab-dyyb is a SQ injection

• For Infliximab-dyyb you must FIRST TX WITH IV INFLIXIMAB THEN CAN USE THE SQ INJECTION FORM

Answer the following about Adalimumab:

• brand name

• class

• indication

• dosage form

• live vaccines?

• same monitoring and ADRs as _____________.

• Humira

• TNF blocker

• indication-moderate/severe UC or Crohn’s inadequate to other therapies

• SQ injection

• NO live vaccines

• same monitoring and ADRs as INFLIXIMAB

What is the difference between Adalimumab and Infliximab?

DOSAGE FORM AND CONTRAINDICATIONS

• Adalimumab is a SQ injection, Infliximab is an IV infusion

• Adalimumab IS NOT CONTRAINDICATED IN class III and IV HF like Infliximab

Answer the following about Golimumab:

• brand name

• class

• indication

• dosage form

• does it have a HF C/I?

• live vaccines?

• Simponi

• TNF blocker

• NOT APPROVED FOR Crohn’s!!!!!! ONLY APPROVED FOR moderate-severe UC inadequate to other therapies

• SQ INJECTION

• NO HF C/I

• NO LIVE VACCINES

Review table for the TNF-blockers in IBD:

Answer the following about Vedolizumab:

• brand name

• class

• indication

• dosage form(s)

• D/I

• potential for _____.

• Entyvio

• inhibits a4/b7 integrin

• indication: moderate/severe UC and Crohn’s

• IV infusion BUT IN UC ONLY can switch to SQ injection after IV infusion

• D/I: do not take with natalizumab or TNF blockers (duh)

• potential for PML

Answer the following about Tofacitinib:

• brand name

• class

• indication

• D/I

• dosage form

• live vaccines?

• BBW

• Pts. with CV risks or RA are at increased risk of ______________.

• monitoring

• Xeljanz

• JAK Inhibitor

• Indicated for moderate/severe UC (NOT CROHN’S!!!)

• D/I: not with TNF blockers or immunosuppressants (ex:thioprines)

• ORAL DOSAGE FORM

• NO LIVE VACCINES

• BBW- INFECTIONS (must monitor for TB)

• increased risk of thrombosis

• monitoring: lymphocytes, neutrophils, Hgb, LFTs

What’s the difference between Tofacitinib (Xeljanz) and Upadacitinib (Rinvoq)?

INDICATION

• Tofacitinib- only for UC

• Upadacitinib- for UC AND CROHN’s

(DISCLAIMER: there’s other small differences but for the test I would just group these 2 together and just remember the indication is different, we have too many dang drugs to remember to be picky)

Answer the following about Ustekinumab:

• brand name

• class

• indication

• dosage form

• monitoring

• live vaccines?

• Stelara

• IL 12 and 23 antagonist

• moderate-severe ulcerative colitis UC and Crohn’s

• IV to SQ

• monitor for TB

• NO LIVE VACCINES

Answer the following about Risankizumab:

• name

• class

• indication

• dosage form

• monitoring

• live vaccines?

• Skyrizi

• IL-23 antagonist

• moderate-severe ulcerative colitis UC and Crohn’s

• IV to SQ

• monitor for TB, LFTs, bilirubin

• NO LIVE VACCINES

What is the main difference between Risankizumab (Skyrizi) and Ustekinumab (Stelara)?

Risankizumab is an IL-23 antagonist, and Ustekinumab Il-12, 23 antagonist

Answer the following about Ozanimod:

• brand

• class

• indication

• dosage form

• ADRs

• D/I

• live vaccines?

• Zeposia

• Sphingosine 1-phosphate receptor modulator

• moderate-severe ulcerative colitis UC (NOT CROHN’S)

• oral

• ADRs- THINK CARDIAC—> C/I in any kind of MI, angina, stroke, or Class III or IV HF

• D/I: CCB or BB

• NO LIVE VACCINES

With Ozanimod, you MUST have vaccines for what virus?

chickenpox

What other drug has the same class, indication, dosage form, and ADRs are Ozanimod (Zeposia)?

Etrasimod (Velspity)

Answer the following about Mirikizumab-mrkz:

• brand name

• class

• indication

• dosage form

• live vaccines?

• Omvoh

• IL 23p19 antagonist

• moderate-severe ulcerative colitis UC (NOT CROHN’S)

• IV to SQ

• NO LIVE VACCINES

Review table for other IBD meds:

IV steroids is recommended for severe ____.

UC

In acute severe UC that does not improve with IV steroids use _________________.

cyclosporine

Cyclosporine can cause __________toxicity.

nephrotoxicity

PRACTICE:

Which TNF-blocker is only indicated in UC:

a. Infliximab

b. Infliximab-dyyb

c. Adalimumab

d. Golimumab

d

PRACTICE:

Which of the following is not a monitoring parameter for Humira?

a. Hep C

b. TB

c. Chest X-ray

d. lymphocytes

e. LFTs

d

PRACTICE:

Which of the following has a BBW for infections?

a. Upadacitinib

b. Mirikizumab-mrkz

c. Risankizumab

d. Ozanimod

a

Where is Crohn’s located? What is the appearance?

Crohn’s can be anywhere from mouth to anus and has a “cobblestone” appearance

What are some symptoms of Crohn’s?

diarrhea and abdominal pain

What are the 3 classifications of Crohn’s?

1. mild-moderate: Crohn’s disease activity index 150-220, NO DEHYDRATION

2. moderate-severe: Crohn’s disease activity index 220-450

3. severe-fulminant: Crohn’s disease activity index >450

Answer the following about Certolizumab:

• brand

• class

• indication

• dosage form

• same ADRs, and monitoring as ______________.

• Cimzia

• TNF-a blocker

• moderate/severe CROHN’s

• SQ injection

• infliximab

Answer the following about Natalizumab:

• brand

• class

• indication

• dosage form

• D/I

• Tysabri

• inhibits a4 integrin

• moderate/severe CROHN’s

• IV infusion

• can’t take with any immunosuppressants, must taper steroids

With Natalizumab you must have what kind of program because of what ADR?

MUST have a TOUCH prescribing program because of PML risk—> only certain people can prescribe, administer, and dispense

Metronidazole is an antiprotozoal and antibacterial… is it indicated for Crohn’s? If so what is the indication?

not indicated

Ciprofloxacin is a fluoroquinolone antimicrobial agent…is it indicated for Crohn’s? If so what is the indication?

not indicated

Is methotrexate indicated in Crohn’s? If so what is the indication?

not indicated

According to the guidelines, If Crohn’s is located in the terminal ileum/right colon… what tx is preferred?

BUDESONIDE

The combination of infliximab and azathioprine increases the risk of…

Non-Hodgkin’s lymphoma