Downloaded 152 times
Uploaded byAreej Abu Hanieh
Inflammatory Bowel Disease - Pharmacotherapy
Ulcerative colitis and Crohn's disease are forms of inflammatory bowel disease that can affect different parts of the gastrointestinal tract. Ulcerative colitis causes inflammation of the inner lining of the colon, while Crohn's disease causes transmural inflammation that may occur anywhere along the GI tract. Treatment depends on the severity and location of disease, and may include aminosalicylates, corticosteroids, immunosuppressants, antibiotics, and biologic agents. Surgical intervention is sometimes required for complications like toxic megacolon or for severe, treatment-resistant disease. Lifelong maintenance therapy is often necessary to prevent disease flare-ups.
More Related Content
Similar to Inflammatory Bowel Disease - Pharmacotherapy
More from Areej Abu Hanieh
Inflammatory Bowel Disease - Pharmacotherapy
- 1. Inflammatory Bowel disease Ulcerativecolitis & Crohn’s disease 1
- 2. Ulcerative colitis(UC): a mucosal inflammatory condition confined to the rectum and colon. Crohn’s disease (CD): a transmural inflammation of gastrointestinal (GI) mucosa that may occur in any part of the GI tract. Bimodal distribution in Age Affects both genders equally 2
- 3. 1. Immunologic 2. Infectious 3.Genetics 4. Psychological factors 5. Diet/smoking 6. NSAIDS 7. Others OCP, isotretinoin Etiology 3
- 4.
- 5. Feature Crohn’s DiseaseUlcerative Colitis Malaise, fever Common Uncommon Rectal bleeding Common Common Abdominal pain Common Unusual Distribution Discontinuous Continuous Rectal involvement Rare Common Ileal involvement Very common Rare Strictures Common Rare Fistulas Common Rare Crypt abscesses Rare Very common 5
- 6. UC: limitedto colorectal region. Local complications: GIB, hemorrhoids, anal fissures, perirectal abscess, toxic megacolon, cancer. Risk for colorectal carcinoma is higher in chronic UC patients vs. general population. Pathophysiology: 6
- 7. CD: anypart of GI tract but most common is terminal ilium Rectal involvement is less common than UC. Small bowel stricture with subsequent obstruction is a complication that may require surgery. Bleeding with CD is not as severe as UC but pt. may develop anemia. Arthritis, iritis, skin lesions, and liver disease often accompany Crohn disease. Nutritional deficiencies are common. 7
- 8. Hepatobiliary complications. Joint complications Ocular complications Dermatologic & mucocutaneous complications Hematologic, coagulation, metabolic abnormalities Extra-intestinal manifestations 8
- 9. Signs and symptoms •Abdominalcramping •Frequent bowel movements, often with blood in the stool •Weight loss •Fever and tachycardia in severe disease •Blurred vision, eye pain, and photophobia with ocular involvement •Arthritis •Raised, red, tender nodules that vary in size from 1 cm to several centimeters Physical examination •Hemorrhoids, anal fissures, or perirectal abscesses may be present •Iritis, uveitis, episcleritis, and conjunctivitis with ocular involvement •Dermatologic findings with erythema nodosum, pyoderma gangrenosum, or aphthous ulceration Laboratory tests •Decreased hematocrit/hemoglobin •Increased ESR or CRP •Leukocytosis and hypoalbuminemia with severe disease •(+) perinuclear antineutrophil cytoplasmic antibodies Clinical Presentation of Ulcerative Colitis 9
- 10. Signs and symptoms •Malaiseand fever •Abdominal pain •Frequent bowel movements •Hematochezia •Fistula •Weight loss and malnutrition •Arthritis Physical examination •Abdominal mass and tenderness •Perianal fissure or fistula Laboratory tests •Increased white blood cell count, ESR, and CRP •(+) anti–Saccharomyces cerevisiae antibodies Clinical Presentation of Crohn Disease 10
- 11. Goals of treatment: Resolutionof acute inflammatory processes Resolution of complications Alleviation of extraintestinal manifestations Maintenance of remission 11
- 12. Avoid anti-diarrhealmeds, anticholinergics, opiates and NSAIDs. Address diet case-by-case. Vit D and Ca supplementations in all pts on steroids. Surgery case by case Non-pharmacological therapy: 12
- 13. Sulfasalazine, mesalamine,olsalazine, balsalazide. Various delivery mechanisms for 5-ASA (mesalamine) to areas of inflammation in GI tract. Sulfasalazine: S.E: HA,GI symptoms, fatigue C/I: sulfa allergy pts. Meselamine: should not be crushed or chewed. safe in sulfonamide allergies S.E: N/V, HA Pharmacological treatment: Aminosalicylates 13
- 14.
- 15. Prednisone, predinsolone,methylprednisolone, HC, budesonide Rapid suppression of inflammation in IBD May be used PO, IV, or rectally. Should be used for short-term only. S.E: hyperglycemia, cataracts, HTN, skin atrophy, adrenal suppression, osteoporosis, infection risk. Corticosteroids 15
- 16. Azathioprine, mercaptopurine,methotrexate, or cyclosporine. Azathioprine and mercaptopurine are effectively used in long-term treatment of both CD and UC. Reserved for pts who fail ASA or refractory to or dependent on CS. Inhibit inflammation, slow onset (up to months) Cyclosporine: short-term benefit in treating acute, severe UC to avoid colectomy in pts failing CS. MTX: treatment and maintenance of CD IM weekly dosing Immunosuppresants: 16
- 17. TNF-a-targeting antibiodies:infliximab, adalimumab Adhesion molecule inhibitors: natalizumab . Central role in treatment and maintenance of IBD . Infliximab useful as induction and maintenance therapy for moderate-severe active CD and UC disease, steroid- dependent disease, and fistulizing disease Infliximab may suffer loss of efficacy over time 2/2 antibody development. Adalimumab is fully humanized Indicated for moderate-severe CD and UC Indicated in pts who were on infliximab and lost response Natalizumab - Can be used in pts with CD who are unresponsive other therapies, including CS and TNF-a inhibitors . Biological Agents: infliximab, adalimumab, Natalizumab 17
- 18. Metronidazole andciprofloxacin. Antibiotics are often used in patients with perineal CD or when fistulas or abscesses Antimicrobial agents: 18
- 19. Active distaldisease (left sided & proctitis) Can be managed outpatient with oral &/or topical ASA. Topical mesalamine 1st line for inducing remission Enema for left-sided dz. Suppositories for proctitis. Oral & topical mesalamine may be combined in extensive left sided dz. Topical CS 2nd line. Treatment of Ulcerative Colitis Mild to Moderate Active Disease: 19
- 20. Active proximaldisease (transverse colon & up) Oral ASA are 1st line for inducing remission PO CS 2nd line Infliximab 3rd line 20
- 21. Systemic corticosteroidsin those patients who are unresponsive to maximal doses of oral and/or topical mesalamine derivatives Oral doses of 40 to 60 mg prednisone daily Immunosuppressive agents or TNF-α inhibitors Moderate to Severe Active Disease UC: 21
- 22. Requires hospitalization CS for 7-10d regardless of location of dz. If no response to CS after 3-7d of therapy: TNF- α inhhibitors or cyclosporine IV continious May require colectomy Severe-Fulminant UC: 22
- 23. Life-long maintenancetherapy often required. Most common agents used: sulfasalazine, mesalamine derivatives, infliximab, adalimumab, and azathioprine or MP. For distal dz: topical mesalamine (suppository or enema) PO mesalamine or salfasalazine 1st line for maintenance in pts. w/ extensive or proximal dz. Maintenance of Remission in UC: 23
- 24.
- 25. PO sulfasalazine,mesalamine derivatives or budesonide are options for inducing remission ASA not effective in mild-moderate CD but tried as 1st line 2/2 safety Budesonide preferred for ileal &/or right-sided (ascending colong) dz. Mild-Moderate CD 25
- 26. PO CS,such as prednisone 40-60mg/d , are generally considered 1st line therapies for moderate to severe active CD who are unresponsive to ASAs. Hospitalized pts who can’t tolerate PO CS, can be given parenteral steroids (hydrocortisone or methylprednisolone) Infliximab/adalimumab are 2nd line. But 1st line if pt. has fistula Natalizumab is 3rd line. Moderate-Severe CD: 26
- 27. Hospitalization maybe required. IV CS &/or infliximab may be used. Many pts may require colectomy. Severe-fulminant CD: 27
- 28. Indefinite maintenancetherapy often needed. Immunosuppressants (e.g azathioprine) or biologics (infliximab) are preferred. ASA & CS no role Maintenance of Remission in CD: 28
- 29.
- 30. Toxic Megacolon Aggressivefluid and electrolyte management are required for dehydration Steroids in high dosages (hydrocortisone 100 mg every 8 hours) should be administered IV to reduce acute inflammation. Broad-spectrum antimicrobials Anemia: give PO ferrous sulfate. If pt. cant take anything PO, then blood transfusions or IV iron infusions may be required. Selected complications: 30
- 31. Pregnancy: Immunosuppressive drugs(azathioprine and mercaptopurine) may be associated with fetal deformities in humans and are classified as pregnancy category D Use of infliximab should be restricted to the first and second trimesters Breastfeeding: Metronidazole and cyclosporine should not be given. Special Considerations 31
- 32. Therapy successis measured by pt. reported complaints, s/s, by direct clinician examination, labs, QOL. The Crohn Disease Activity Index Standardized assessment tools have also been constructed for UC Evaluation of therapeutic outcomes: 32