inflammatory bowel disease

classic sx of inflammatory bowel disease

bloody diarrhea

flare triggers

infections

use of NSAIDs

certain foods — fatty, gas-producing

mucosal inflammation confined to the rectum and colon with superficial ulcerations (continuous)

a. ulcerative colitis

b. crohn’s disease

a. ulcerative colitis

deep, transmural inflammation that can affect any part of the GI tract (non-continuous)

a. ulcerative colitis

b. crohn’s disease

b. crohn’s disease

ulcerative colitis: distal disease (descending colon and rectum) tx

topical tx

diagnosis of IBD

colonoscopy with tissue biopsy

diet changes to prevent flares

• smaller, more frequent meals

• low in fat and dairy

• add fiber

• drink plenty of water

can antidiarrheals/antispasmodics be used in IBD?

yes, but cautiously and under supervision of healthcare provider

T/F vitamin supplements should be used in IBD to help prevent deficiencies related to malabsorption

TRUE

_____ can reduce abdominal pain, bloating, urgency, constipation, or diarrhea

probiotics — Lactobacillus or Bifidobacterium infantis

nicotine and cigarette smoking are protective in which disease?

a. ulcerative colitis

b. crohn’s disease

a. ulcerative colitis

what is used to treat acute exacerbations of IBD?

short courses of oral or IV steroids

in general can we continue drugs that we used for induction for maintenance?

YES — not systemic steroids tho

crohn’s disease — mild disease of ileum and/or right colon meds

oral budesonide for ≤ 3 months, then d/c or change to a thiopurine or methotrexate

crohn’s disease — moderate-severe disease meds

• anti-TNF drug ± methotrexate or a thiopurine

• IL receptor antagonist

• integrin receptor antagonist

alternatives: JAK inhibitor

ulcerative colitis — mild disease meds

mesalamine (5-ASA)

distal: rectal

extensive: rectal ± oral

ulcerative colitis — moderate-severe disease meds

• anti-TNF drug ± a thiopurine

• IL receptor antagonist

• integrin receptor antagonist

• oral sphingosine 1-phosphate receptor modulator

alternatives: JAK inhibitor

oral steroids used for IBD

prednisone

budesonide (Entocort EC, Uceris)

what form of budesonide is for crohn’s disease only?

a. Entocort EC - delayed release cap

b. Uceris - extended release tab

a. Entocort EC - delayed release cap

what form of budesonide is for ulcerative colitis only?

a. Entocort EC - delayed release cap

b. Uceris - extended release tab

b. Uceris - extended release tab

short-term oral steroids ADRs

• increased appetite/weight gain

• emotional instability

• insomnia

• fluid retention

• indigestion

long-term oral steroids ADRs

• adrenal suppression/Cushing’s

• impaired wound healing

• incr. BP

• incr. BG

if using oral steroids for ______, must taper to avoid withdrawal sx

> 2 weeks

what is a method to decrease adrenal suppression caused by oral steroids?

alternate day therapy

what to monitor if long-term use of steroids is required?

bone density

-optimize calcium and vitamin D intake

-consider bisphosphonates

budesonide has ____ systemic exposure than other oral steroids

a. more

b. less

b. less

rectal steroids (hydrocortisone and budesonide) are indicated for ______

a. ulcerative colitis

b. crohn’s disease

c. both

a. ulcerative colitis

budesonide is a major ______

substrate of CYP3A4

aminosalicylates are indicated for the treatment of ______

a. ulcerative colitis

b. crohn’s disease

c. both

a. ulcerative colitis

aminosalicylates

• sulfasalazine (Azulfidine)

• mesalamine

  • ER caps: Pentasa, Apriso, Delzicol

  • DR tabs: Lialda

  • enema: Rowasa

  • suppository: Cansa

• balsalazide (Colazal)

• olsalazine (Dipentum)

CI to sulfasalazine

salicylate or sulfa allergy

which aminosalicylate is available in both oral and rectal formulations?

a. sulfasalazine

b. mesalamine

c. balsalazide

d. olsalazine

b. mesalamine

CI to aminosalicylates (mesalamine, sulfasalazine, balsalazide, olsalazine)

salicylate allergy

mesalamine ER capsules

Pentasa

Apriso

Delzicol

mesalamine DR tablets

Lialda

mesalamine enema

Rowasa

mesalamine suppository

Canasa

how long do you retain the mesalamine suppository (Canasa) for induction?

≥ 1-3 hours

how long do you retain the mesalamine enema (Rowasa) for induction?

overnight

what aminosalicylate can leave a ghost tablet in the stool?

a. Azulfidine

b. Lialda

c. Apriso

d. Delzicol

d. Delzicol

ADRs of balsalazide (Colazal)

staining of teeth/tongue if opened

thiopurines

azathioprine (Azasan, Imuran)

mercaptopurine (Purixan)

azathioprine

Azasan

Imuran

mercaptopurine

Purixan

warnings for azathioprine (Azasan, Imuran)

• hematologic toxicities

• myelosuppression

  • incr. risk if genetic deficiency of TPMT

what kind of genetic testing should we consider prior to azathioprine?

thiopurine methyltransferase (TPMT)

-deficiency —> incr. risk of myelosuppression

which of the following is true?

a. mercaptopurine is metabolized to azathioprine

b. azathioprine is metabolized to mercaptopurine

b. azathioprine is metabolized to mercaptopurine

tx options for moderate-severe disease and/or that failed tx for mild disease

• sphingosine 1-phosphate (S1P) receptor modulators

• JAK inhibitors

• biologics

  • anti-TNF monoclonal antibodies

  • IL receptor antagonists

  • integrin receptor antagonists

• methotrexate

S1P receptor modulators MOA

block lymphocytes from exiting the lymph nodes —> reducing lymphocytes in the intestines

S1P receptor modulators

ozanimod

etrasimod

JAK inhibitors

upadacitinib

tofacitinib

anti-TNF monoclonal antibodies

infliximab

adalimumab

IL receptor antagonists

ustekinumab

risankizumab

guselkumab

mirikizumab

integrin receptor antagonists MOA

bind to integrin molecules —> prevents inflammatory cells from migrating into GI tissue

integrin receptor antagonists

natalizumab (Tysabri)

vedolizumab (Entyvio)

natalizumab (Tysabri) dosing

IV over 1 hour every 4 weeks

natalizumab (Tysabri) BBW

progressive multifocal leukoencephalopathy (PML)

REMS TOUCH program

vedolizumab (Entyvio) IV dosing

over 30 minutes at 0, 2, and 6 weeks, then every 8 weeks

vedolizumab (Entyvio) SC dosing

every 2 weeks after > 2 IV infusions

when do you discontinue vedolizumab (Entyvio)?

if no benefit by week 14

vedolizumab (Entyvio) warnings

infusion reactions

infections

immunizations — up to date prior to starting; avoid live vaccines

dosing of methotrexate for CD

weekly IM or SQ injection

S1P receptor modulators approved for UC

• ozanimod

• etrasimod

JAK inhibitors approved for UC

• upadacitinib

• tofacitinib

JAK inhibitors approved for CD

upadacitinib

anti-TNF monoclonal antibodies approved for UC and CD

infliximab

adalimumab

IL receptor antagonists approved for UC

• ustekinumab

• risankizumab

• guselkumab

• mirikizumab

IL receptor antagonists approved for CD

• ustekinumab

• risankizumab

integrin receptor antagonists approved for UC and CD

• natalizumab (Tysabri)

• vedolizumab (Entyvio)