Inflammatory Bowel Disease

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  • Created by: LBCW0502
  • Created on: 07-04-21 17:18
What is Crohn's Disease?
Can affect any part of the GIT. Patchy ulceration (not continuous), transmural inflammation. Defined by location or by pattern (inflammatory, fistulating or stricturing). Common in ileum and colon. Symptoms depend on location and pattern.
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What is a fistula?
Inappropriate opening of two different compartments e.g. bowel and bladder
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Which is a stricture?
Narrow part of the bowel, can be impartial (issues with digesting products)
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What is Ulcerative Colitis?
Continuous progressive generalized epithelial ulceration. Diffusion mucosal inflammation (superficial). Limited to the colon. Broadly divided into distal (lower/left-sided, rectum, sigmoid colon) and more extensive disease (L-sided colitis, pancolitis
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What are the clinical features of CD?
Acute/insidious onset of symptom (heterogenous). Mild-moderate, moderate-severe, severe-fulminant. Weight loss, fever, general malaise/tiredness. Diarrhoea with blood. Abdominal pain (RLQ/central). Palpable tender mass (lower abdomen). Malabsorption
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What are the clinical features of UC?
Often abrupt onset with some chronic symptoms. Mild, Moderate, Severe, Fulminant. Severe diarrhoea with blood and mucous colic and urgency. Left sided pain, anaemia, nausea, vomiting, dehydration, lower abdominal cramps and pain on defaecation, fever
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What are the complications with CD?
Strictures (narrowing, common in CD, indication that CD is not well controlled), dietary restriction (triggers), vitamin deficiencies and anaemia (chronic diarrhoea, gut is not functioning properly, unable to absorb nutrients/vitamins
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How can UC be cured?
Surgery to remove colon
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Describe the management of mild-moderate CD
Induce remission: oral steroids (prednisolone) or budenoside/5-ASA if prednisolone not tolerated and distal ileal, ileocecal. Induce remission with add on therapy - azathioprine/mercaptopurine or MTX (if >2 exacerbations in 12 months or steroids can't be
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What is the difference between prednisolone and budesonide?
Budesonide has fewer systemic side effects due to high and fast metabolism
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Describe the management of moderate-severe (active) CD
Induce remission: glucocorticoids (PO/IV), consider using infliximab, adalimumab, vedolizumab or ustekinumab. Induce remission with add on therapy: azathioprine/mercaptopurine or MTX. Maintenance: infliximab, adalimumab, vedolizumab or ustekinumab
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Describe the management of fistulating disease
Induce remission: antibiotics/drainage, consider infliximab or adalimumab. Induce remission with add on therapy: azathioprine/mercaptopurine or MTX. Maintenance: infliximab or adalimumab, potentially with azathioprine/mercaptopurine or MTX.
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Describe the management of mild UC
Induce remission: oral 5-ASA (use topical if L-sided disase or proctitis either alone or in combination with oral 5-ASA). And/or: topical steroid (if L-sided or proctitis) or an oral steroid (beclomethasone, budesonide or prednisolone).
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Describe the management of moderate UC
Induce remission: oral 5-ASA AND/OR
Oral beclomethasone/budesonide or prednisolone if cannot tolerate/ contraindications to 5-ASA or no improvements after 4 weeks of 5- ASA therapy
AND Tacrolimus if inadequate response to oral prednisolone after 2–4 weeks
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Describe the management of severe UC
Induce remission: IV corticosteroids (e.g. hydrocortisone) AND
IV ciclosporin in those who cannot tolerate or have contraindications to corticosteroids, or who’s symptoms do not improve after 72 hours of IV steroid therapy OR Infliximab ‘rescue therapy’
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Describe features of systemic treatment vs local treatment
Topical treatments available if disease location is suitable. 5-ASAs & steroids can have a local effect. 5-ASAs mainly for UC. Budesonide- Care with formulations regarding indication. Cortiment – UC (colonic distribution), Entocort/ Budenofalk – CD
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Describe features of acute treatment vs chronic treatment
Fast onset - steroids, 5-ASAs, anti-TNFs, ciclosporin. Slow onset - Azathioprine/ Mercaptopurine/ Methotrexate, 2-3 months for onset of action.
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Which factors need to be considered when looking at disease severity?
Can you wait for slow-onset drugs to take effect?. Is there evidence that drug induces remission or maintains remission? Is the drug cost-effective in that severity of disease? Is treatment suitable for long-term treatment? Steroids- aim to wean once
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What are the co-morbidities to consider when managing IBD?
Heart failure - Steroids (fluid retention), Infliximab (worsens heart failure). Diabetes - Steroids (can affect glycaemic control). Osteoporosis - Avoid repeated courses of steroids. Pregnancy - Azathioprine/Mercaptopurine? Methotrexate?
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What are the other factors to consider?
Patient decisions. Drug license. Tablet size/strength. Availability of soluble or liquid preps. Previous intolerances or allergy. NICE Guidelines. Monitoring requirements. Interactions
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What are the counselling points for methotrexate and folic acid? (1)
Methotrexate should be 25 mg once a week (15 mg is a starting dose). Need to make sure that folic acid is 5 mg once a week on a different day to methotrexate. One strength of MTX – only 2.5 mg tablets (10 tablets once a week). Counselling
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What are the counselling points for methotrexate and folic acid? (2)
Full blood count – CRP, WBC, neutrophils, platelets. Renal tests – CrCl, eGFR. Liver tests – AST, ALT, Lung function - SOB. Repeat every 1-2 weeks until therapy is stabilised then every 2-3 months. Symptoms of infection e.g. sore throat.
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What are the counselling points for methotrexate and folic acid? (3)
Must avoid becoming pregnant during treatment with MTX and for at least 3-6 months after the end of treatment (cover with AZA with biologic, or trial without medication). NPSA medication safety alert – need monitoring booklet for MTX when dispensing medic
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What are the counselling points for thiopurines? (1)
TMPT test (thiopurine methyltransferase) - enzyme used to metabolise thiopurines (AZA to 6-MP to thioguanine). NUDT15 gene – responsible for breakdown of AZA in the body. Check of immune infections. Vaccinations
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What are the counselling points for thiopurines? (2)
TMPT level should be taken. 26-50 (homozygous, normal, high activity) – 2-2.5 mg/kg/day of AZA. 10-15 (heterozygote intermediate) – 1 mg/kg. <10 (homozygous deficient) – avoid or 5-10 mg/day. Weight based. E.g. 34 level give 2 mg/kg/day, weight of 75 mg
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What are the counselling points for thiopurines? (3)
Report any signs of infection, bleeding bruising. AZA dosing. Take after food if they experience nausea. Try to take drug at night to prevent nausea and vomiting. Flu -like symptoms can occur 2-3 weeks when taking drug. Monitor FBC, LFT, CRP, TGN, MMP
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What are the counselling points for thiopurines? (4)
Steroid sparing considered for – patients needing 2+ steroid courses a year, those with disease relapsing as dose of steroid reduced <15 mg OD, if relapse within 6 weeks of stopping steroids. Thiopurines – long onset of action. Steroids – short onset
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What are the key points for infliximab?
Can worsen the HF. Steroids – fluid retention in HF. Other information needed – other drug treatment for asthma and HF, severity of HF (mild/caution or moderate/avoid). HBI – Harvey-Bradshaw Index (higher score, more severity). Biologic can be used
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What are the key points for azathiopurine and prednisolone?
Decrease AZA dose to 25% or 33% . Blocking metabolism, increase thiopurine levels. HBI can’t be used for people with stomas (can’t get a score), used for CD not UC, doesn’t cover all symptoms (e.g. CD in the mouth). Prednisolone used to cover AZA then wea
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Describe features of budesonide
Mezavant – pH triggered formation of gel complex to coat colon (release at pH >7), for terminal ileum and colon. Budenofalk – Entocort CR (for CD) – release from ileum and ascending colon, released after 2-3 hours (works in terminal ileum and secum).
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Card 2

Front

What is a fistula?

Back

Inappropriate opening of two different compartments e.g. bowel and bladder

Card 3

Front

Which is a stricture?

Back

Preview of the front of card 3

Card 4

Front

What is Ulcerative Colitis?

Back

Preview of the front of card 4

Card 5

Front

What are the clinical features of CD?

Back

Preview of the front of card 5
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