most common location of Crohn's disease occurrence
ileum (end of small intestine)
tissue layer affected by UC
mucosa (rarely below)
characterization of UC inflammation
continuous inflammation throughout affected area
disease affecting majority of colon
pancolitis
tissue layer(s) affected by Crohn's disease
can penetrate all layers through the bowel wall (mucosa, submucosa, muscularis, serosa)
penetration through bowel wall into other organs
fistula
characterization of Crohn's disease inflammation
"cobblestoning" - unequal inflammation throughout
polyps
cause of growth retardation in Crohn's
large amount of nutrition is absorbed at the ileum -> inflammation prevents absorption
perianal disease: UC vs Crohn's
UC has none
common in Crohn's
4 levels of disease severity
1) mild
2) moderate
3) severe
4) fulminant
4 therapeutic goals of IBD treatment
1) induce/maintain remission
2) resolve complications
3) alleviate systemic sx
4) improve QOL
drug treatment options for IBD (6)
1) 5-aminosalicylates (5-ASA)
2) antibiotics
3) corticosteroids
4) immunomodulators
5) biological response modifiers (-mab's)
6) adjunctive therapies
3 things to assess to start treatment
1) which disease (UC vs CD)
2) severity
3) extent/location of disease
adjunctive therapies for IBD (2)
1) loperamide (Imodium)
2) antispasmodics
THESE DON'T TREAT THE DISEASE
antispasmotic drugs (2)
1) dicyclomine
2) hyocyamine
mesalamine
5-aminosalicylate
treats mild to severe UC, mild to moderate CD
mostly topical effects (has to be delivered to site of action)
patients to avoid treating w/ sulfasalazine
sulfa allergic
non-sulfa 5-ASA drugs (3)
1) mesalamine
2) olsalazine
3) balsalazide
formulation if disease located in colon
oral
formulation if disease located in descending colon (INCLUDING splenic flexure) & rectum
enema
formulation if disease located in rectum
suppository
type of agents superior for distal disease
topical 5-ASA agents
if IBD unresponsive to 5-ASA, next line treatment
corticosteroids
only corticosteroid that is indicated as 1st line treatment of mild-moderate IBD
budesonide
MOA of immune modulating drugs
purine antagonists
drug class of azathioprine & 6-mercaptopurine
immune modulators
indicated for immune modulating drugs
used to wean patients off steroid dependency
MOA of methotrexate
folate antagonist
indications for methotrexate
mod/severe Crohn's disease
immuno modulator onset of action
3-15 MONTHS
chimeric mAb targeting TNF
indicated for mod/severe IBD ***very effective for fistulizing CD***
infliximab (Remicade)
only available as IV
recombinant IgG to TNF
indicated for mod/severe IBD in pts resistant to other tx
adalimumab (Humira)
PEG + chimeric Fab (fragmetn of humanized TNF inhibitor mAb) against TNF
certolizumab (Cimzia)
- humanized mAb against 4-integrin
- interferes w/ leukocyte adhesion
- indicated for mod/severe CD after failure of all other therapies
- has black box warning
natalizumab (Tysabri)
first biologic agent to start pt off with
inflixmab (Remicade)
indications for antibiotic use in IBD
typically used only in CD
more effective for ileocolitis & colitis than isolated small bowel disease
usually in combo w/ 5-ASA
abx used in CD treatment (2)
1) metronidazole
2) ciprofloxacin
alternative therapy used short-term for steroid refractory UC or Crohn's and/or fistulizing Crohn's disease
cyclosporine
improves symptoms in patients with UC, but exacerbates them in Crohn's
smoking/nicotine patches
**DO NOT RECOMMEND FOR PATIENTS WITH CD***
mild UC treatment
5-ASAs (any formulation)
CCS enema
moderate UC treatment
5-ASAs, CCS enema PLUS oral CCS
(may add immune modulator or infliximab if no response)