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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
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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
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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
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Lifestyle Modifications in IBD
- 1. decrease fiber
- 2. low residue diet
- 3. Smoking cessation in CD HOWEVER LINKED TO FLARES IN UC
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Distal UC
Lowest part of the colon and rectum where a suppository can work (< or = to 10 cm up)
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Treatemnt of Distal UC: Mild
- 1. Rectal or oral aminosalicylate
- 2. Rectal glucocorticosteroid (hydrocortisone enema ex.)
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Treatment of Distal UC: Moderate
- > 4 bloody stools per day
- 1. Rectal or oral aminosalicylate
- 2. Rectal glucocorticosteroid
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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
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Treatment of Distal UC: Refractory
oral or IV glucocorticosteroid PLUS azathioprine or 6-MP (steroid sparing)
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Treatment of Extensive UC: Mild
1. Topical AND oral aminosalicylate
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Treatment of Extensive UC: Moderate
Topical AND oral aminosalicylate
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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)
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Treatemnt of Extensive UC: Refractory
1. oral or IV steroid PLUS azathioprine or 6-MP or infliximab or adalimumab or cyclosporine
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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
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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)
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Treatment of CD: Severe
- 1. oral or IV steroid (if acute need)
- 2. Methotrexate (dose limit steroid)
- 3. Infliximab, adalimumab, natalizumab, or certolizumab
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Treatment of CD: Refractory
- TNF-a
- 1. Infliximab
- 2. adalimumab
- 3. certolizumab
- 4. natalizumab
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Treatment of CD: perianal
- 1. oral antibiotics (metronidazole)
- 2. Azathioprine or 6-MP
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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
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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
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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
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Olsalazine
- Dimer of two 5-ASA
- WORKS ONLY IN THE COLON AND KNOWN TO CAUSE SEVERE DIARRHEA
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Balsalazide
WORKS ONLY IN THE COLON and is a mesalamine produrg
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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
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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
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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
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Immunosuppressants used in IBD
- 1. Thiopurines (steroid sparing drugs)
- 2. Methotrexate (steroid sparing also) ONLY INDICATED FOR CD
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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)
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Methotrexate
- FOR CD ONLY
- ADR: bone marrow suppresion
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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
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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
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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
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Adalimumab
- Place in therapy: mod to severe CD or UC
- SC injection
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Certolizumab and Natalizumab
Moderate to Severe CD ONLY
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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
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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)
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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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