IBD Pharmacotherapy

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Author:
pcspstudent
ID:
177004
Filename:
IBD Pharmacotherapy
Updated:
2012-10-11 12:13:58
Tags:
IBD
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Description:
Treatment of Irritable Bowel Disease
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  1. Chron's Dx Review
    • Can affect anywher from the mouth to anus and can come back
    • Cannot be cured
    • Tough to taper steroids in these patients
  2. Ulcerative Colitis Review
    • Effect the colon the most
    • Linked to colon cancer
    • Can be cured
    • Can do a colectomy most of the time to cure
  3. IBD Severity
    • Mild: <4 blood stools per day, pulse <90, hemodynamically stable
    • Moderate: 4 or more bloody stools/day, pulse < or = to 90, hgb >10.5
    • Severe: > or = to 6 bloody stools per day, pulse >90bpm, and hemodynamically unstable
  4. Lifestyle Modifications in IBD
    • 1. decrease fiber
    • 2. low residue diet
    • 3. Smoking cessation in CD HOWEVER LINKED TO FLARES IN UC
  5. Distal UC
    Lowest part of the colon and rectum where a suppository can work (< or = to 10 cm up)
  6. Treatemnt of Distal UC: Mild
    • 1. Rectal or oral aminosalicylate
    • 2. Rectal glucocorticosteroid (hydrocortisone enema ex.)
  7. Treatment of Distal UC: Moderate
    • > 4 bloody stools per day
    • 1. Rectal or oral aminosalicylate
    • 2. Rectal glucocorticosteroid
  8. Treatment of Distal UC: Severe
    • > 6 blood stools per day (not likely to occur in distal)
    • 1. Rectal AND oral aminosalicylate
    • 2. Oral or IV glucocorticosteroid
    • 3. Rectal glucocorticosteroid
  9. Treatment of Distal UC: Refractory
    oral or IV glucocorticosteroid PLUS azathioprine or 6-MP (steroid sparing)
  10. Treatment of Extensive UC: Mild
    1. Topical AND oral aminosalicylate
  11. Treatment of Extensive UC: Moderate
    Topical AND oral aminosalicylate
  12. Treatment of Extensive UC: Severe
    • 1. IV glucocorticosteroid
    • 2. IV cyclosporine ( if you try everything and you want to avoid a colectamy)
    • 3. Infliximab OR adalimumab (humera)
  13. Treatemnt of Extensive UC: Refractory
    1. oral or IV steroid PLUS azathioprine or 6-MP or infliximab or adalimumab or cyclosporine
  14. Treatment of CD: Mild
    • 1. Aminosalicylate for colonic dx only
    • 2. Metronidazole or cipro for perineal dx only
    • 3. Budesondie for ileal or right sided colon dx
  15. Treatment of CD: Moderate
    • 1. oral steroid (harder to taper in CD)
    • 2. Azathioprine or 6-MP (steroid sparing helps taper)
    • 3. Methotrexate (another steroid sparing option)
    • 4. Infliximab, adalimumab, natalizumab, or certolizumab (TNF-a)
  16. Treatment of CD: Severe
    • 1. oral or IV steroid (if acute need)
    • 2. Methotrexate (dose limit steroid)
    • 3. Infliximab, adalimumab, natalizumab, or certolizumab
  17. Treatment of CD: Refractory
    • TNF-a
    • 1. Infliximab
    • 2. adalimumab
    • 3. certolizumab
    • 4. natalizumab
  18. Treatment of CD: perianal
    • 1. oral antibiotics (metronidazole)
    • 2. Azathioprine or 6-MP
  19. Aminosalicylate therapy or 5-ASA Place in therapy
    • First line in mild to moderate UC and mild CD
    • Works primarily in the COLON and takes 2-4 weeks to take effect
    • Drugs: Sulfasalazine, Mesalamine, Olsalazine, Balsalazine
  20. Sulfasalazine
    • Sulfa moity: carries the drug to the colon and causes ADR: bone marrow suppression, thrombocytopenia, folic acid def
    • 5-ASA component: has a TOPICAL effect in the colon
    • ONLY WORKS IN THE COLON NOT THE ILEUM
  21. Mesalamine
    • Drugs working in colon only: Apriso enteric granules single daily dose, lialda single daily dose tablets
    • Drugs working in the rectum only: suppository
    • Drugs working in the rectum and colon: rectal enema
    • Drugs working in the colon and ileum: Asacol
    • Drugs working in the colon and small bowel: pentasa
  22. Olsalazine
    • Dimer of two 5-ASA
    • WORKS ONLY IN THE COLON AND KNOWN TO CAUSE SEVERE DIARRHEA
  23. Balsalazide
    WORKS ONLY IN THE COLON and is a mesalamine produrg
  24. Corticosteroids in IBD
    • USED IN: moderate to severe UC and CD unless its budesonide which is used in MILD TO MODERATE ileal or right sided CD
    • Next step when inadaquate response to 5-ASAs
  25. Steroids in UC
    • 1. Typical oral: Predinisone 40-60mg daily then taper
    • 2. IV: Hydrocortisone 300mg daily or methylprednisolone 60mg daily (used in severe acute pts)
    • 3. Topical: hydrocortisone (distal only)
    • 4. DO NOT USE LONG TERM IN UC
  26. Steroids in CD
    • Budesonide: mild to moderate cases of ileal or right sided CD (note: effectiveness lost after 6 months and this ONLY WORKS TOPICALLY SO LESS ADR)
    • Oral steroids: for pts who fail 5-ASA and budesonide
    • IV steroids: severe or fulminant dx or those unable to tolerate oral
  27. Immunosuppressants used in IBD
    • 1. Thiopurines (steroid sparing drugs)
    • 2. Methotrexate (steroid sparing also) ONLY INDICATED FOR CD
  28. Thiopurines
    • Azathioprine or mercaptopurine are used for pts refactory to 5-ASA therapy or steroids or those who need help with steroid withdrawl
    • NOTE: takes approx. 6 months to take effect
    • ADR: infections, leucopenia
    • MONITORING: CBC and TPMT (enzyme def pts are at a hgher risk of bone marrow suppresion and require a lower dose)
  29. Methotrexate
    • FOR CD ONLY
    • ADR: bone marrow suppresion
  30. Calcineurin Inhibitors
    • CYCLOSPORINE
    • UC ONLY
    • Place in therapy: short term therapy of acute, severe, active UC refractory to IV steroid and those wishing to avoid colectamy
    • ADR: nephro/neurotoxicity
  31. TNF-a Inhibitors
    • AVOID IN PTS WITH TB OR HF (do a skin test and chest radiograph to confirm TB presence)
    • Risk of Lymphoma esp with thiopurines also present
    • Drugs: infliximab, adalimumab, certolizumab, natalizumab
  32. Infliximab
    • Place in therapy: moderate to severe UC and CD
    • Note: used in steroid dependent or fistulizing dx (heal fistulas)
    • Can lose effectiveness over time
  33. Adalimumab
    • Place in therapy: mod to severe CD or UC
    • SC injection
  34. Certolizumab and Natalizumab
    Moderate to Severe CD ONLY
  35. Antimicrobials in IBD
    • Metronidazole: 20mg/kg/daily USED IN PERINEAL CD
    • ADR FOR METRONIDAZOLE: NEUROPATHY
    • Cipro is an alternative and can be used in combo with metro
  36. DRUGS NOT TO USE
    • May Causes Toxic Megacolon:
    • 1. Loperamide
    • 2. Antispasmotics
    • 3. Opiates
    • 4. Anticholinergics
    • ALSO hypo kalemia/magnesemia can cause it too (aggressively correct)
  37. IBD in pregnancy
    • folate supplementation with Sulfasalazine is warranted
    • Infliximab, adalimumab are safe
    • avoid LONG TERM use of metronidazole
    • ABSOLUTELY DO NOT GIVE METHOTREXATE

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