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