1. Clinical Case
C.M., a 25-year-old female college student, has had episodic, watery diarrhea and
colicky abdominal pain relieved by defecation for the past 9 months.
Eight weeks before, the diarrhea increased to 3 to 5 semi-formed stools daily. The
frequency of the stools gradually increased to 5 to 10 times a day 1 week ago.
At that time, C.M. noted bright red blood in the stools.
She feels a great urgency to defecate, even though the volume is small.
No H/O recent infection or travel to endemic area.
C.M. complains of anorexia and a 10-lb weight loss over the past 2 months.
For the past 4 months, she has had intermittent swelling, warmth, and tenderness of
the left knee, which is unassociated with trauma.
C.M. appears to be a slightly anxious and tired young woman of normal body habitus.
Her temperature is 100°F; her pulse rate is 100 beats/minute and regular
Physical examination is normal, except for evidence of acute arthritis of the left knee
and tenderness of the left lower abdomen to palpation.
Stool examination shows a watery effluent that contains numerous red and white
cells with no trophozoites. Stool cultures and an amebiasis indirect hemagglutination test are negative.
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2. Clinical Case
Laboratory Data include hematocrit (HCT), 32% , hemoglobin (Hgb),
8.5 g/dL ; white blood cell (WBC) count, 15,000/mm 3 with 82% PMNs ;
ESR, 70 mm/hour ; serum albumin, 2.4 g/dL and alanine
aminotransferase (ALT), 55 U/mL
Sigmoidoscopy showed evidence of granular, edematous, and friable
mucosa with continuous ulcerations extending from the anus
throughout the colon.
What is the most likely cause of C.M.'s diarrheal illness, and what is
the evidence for this?
How should the signs and symptoms be managed and monitored?
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4. ILO’s
Define IBD and its types
Differentiate between UC and CD
Discuss the proposed etiologies of inflammatory bowel disease
(IBD).
Identify the common extra-intestinal manifestations associated
with IBD.
Describe the typical clinical presentation of UC and CD,
Describe the major complications of IBD and their
management.
Formulate treatment goals for management of patients with
active IBD.
Discuss the role of nutritional and surgical interventions in the
management of patients with IBD.
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5. ILO’s
Explain the pharmacologic options for remission
for patients with active UC or CD.
List the main adverse effects of drugs used
Construct monitoring plan for evaluating the
efficacy and toxicity of Drugs used
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7. Forms of IBD
“The
two clinically distinguished forms of
inflammatory bowel diseases (IBD), which are chronic
remittent or progressive inflammatory diseases
Crohns disease (CD)
affect the gastrointestinal tract
Ulcerative colitis (UC)
only the colonic mucosa.
Both genetic and environmental factors contribute to
the pathophysiology of IBD”
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8. Two Forms of IBD
Ulcerative Colitis, a mucosal inflammatory
condition confined to the rectum and colon
Crohn's disease, a transmural inflammation of
gastrointestinal (GI) mucosa that may occur in
any part of the GI tract
The etiologies of both conditions are unknown,
but may have a common pathogenetic
mechanism.
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10. Ulcerative colitis
is categorized
according to
location:
Proctitis involves only
the rectum
Proctosigmoiditis
affects the rectum and
sigmoid colon
Left-sided colitis
encompasses the entire
left side of the large
intestine
Pancolitis inflames the
entire colon
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12. Epidemiology
Most common in Westernized countries such as the United States.
UC affects up to 500,000 people and CD affects up to 480,000 people
in US
The age of initial presentation of IBD is bimodal,
between the age ranges of 20 to 40 years or
60 to 80 years.5
The peak incidence of CD occurs in the second and third decades of life,
with a smaller peak in the fifth decade.2,5 Peak incidence of UC occurs
between the ages of 15 and 25 years.6
Men and women are approximately equally affected
Whites are affected more often than blacks,
Jewish have higher incidences of IBD.
Greatest risk factors is a positive family history of the disease.
The incidence of IBD is 10 to 40 times greater in patients with a first-
degree relative who has IBD compared to the general population
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17. Initiating Perpetuatin Immunoregulator Tissue
Clinical
events g events → y abnormalities → damage → symptom
→
s
Infection Luminal
s
bacteria
Genetic
susceptibility
PMN
Diarrhea
Macrophage
Toxins
T lymphocytes
↑IL-1/IL-1ra
TH1 vs. TH2
Tx, LT, PAF Bleeding
O2, NO
NSAIDs
Bacterial
products
Dietary
antigens
HLA-DR?
Anitgen
presentation
Proteases
Pain
Complemen
t
↓Weight
IFN-γ TNF-α
Pathophysiology of IBD
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18. Clinical Presentation: IBD: General
Signs and symptoms
Abdominal cramping
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, and 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 erythrocyte sedimentation rate
Leukocytosis and Dr Afzal Haq Asif
hypoalbuminemia with severe disease
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21. Comparison of the Clinical and Pathologic Features of Crohn and colitis
22. 1.ULCERATIVE COLITIS
Patholophysiology:
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confined to the colon and rectum
affects primarily the mucosa and the submucosa
The primary lesion occurs in the crypts of the mucosa (crypts of
Lieberkuhn) in the form of a crypt abscess
minor complications include hemorrhoids, anal fissures, or
perirectal abscesses.
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23. Complications of UC
Toxic Megacolon: a severe condition that
occurs in up to 7.9% of ulcerative colitis
patients admitted to hospitals.
High fever, tachycardia, distended abdomen,
elevated white blood cell count, and a dilated
colon
Colonic Carcinoma:
Risk is much greater in patients with ulcerative
colitis as compared with the general population
Hepato-biliary Complications:
Approximately 11% of patients have fatty liver,
pericholangitis, chronic active hepatitis,
cirrhosis, sclerosing cholangitis,
cholangiocarcinoma, and gallstones
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24. Complications of UC
Arthritis:
Common, asymptomatic and migratory.
involves one or a few large joints such as the
knees, hips, ankles, wrists, and elbows.
Ocular Complications:
iritis, epi-scleritis, and conjunctivitis) occur
in up to 10% of patients.
Dermatologic or Mucosal complications:
5 to 10% of patients experience (erythema
nodosum, pyoderma ganrenosum, aphthous
stomatitis
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25. Grading of UC (Montreal classification
S0 Clinical
remission
Asymptomatic
S1
Mild UC
Passage of four or fewer stools/day (with
or without blood), absence of any systemic
illness, and normal inflammatory markers
(ESR)
S2
Moderate UC
S3
Severe UC
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Passage of more than four stools per day
but with minimal signs of systemic
toxicity
Passage of at least six bloody stools daily,
pulse rate of at least 90 beats per minute,
temperature of at least 37.5°C,
haemoglobin of less than 10.5 g/100 ml,
Dr Afzaland ESR of at least 30 mm/h
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26. Fulminant UC
Severe diarrhea with abdominal pain, bleeding,
fever, sepsis, electrolyte disturbances, and
dehydration.
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28. 2. CROHN'S DISEASE: Pathophysiology
Trans-mural inflammatory process.
Terminal ileum is the most common site
but may occur in any part of the GI tract.
Two thirds of patients have some colonic
involvement,
15% to 25% of patients have only colonic
disease.
Complications :
May involve the intestinal tract or organs
unrelated to it.
Small-bowel stricture and subsequent
obstruction: may require surgery.
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30. Crohn’s disease:Clinical presentation
Highly variable
A single episode or continuous,disease.
A patient may present with diarrhea and
abdominal pain or a perirectal or perianal lesion
Periods of remission and exacerbation.
Some patients may be free of symptoms for years, while
others experience chronic problems in spite of medical
therapy
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31. Crohn’s Disease: Clinical presentation
Signs and symptoms
Malaise and fever
Abdominal pain
Frequent bowel movements
Hemotachezia (bright red blood per rectum: BRBPR)
Fistula (an abnormal connection or passageway between two epithelium-
lined
organs or vessels that normally do not connect)
Weight loss
Arthritis
Physical examination
Abdominal mass and tenderness
Perianal fissure or fistula
Laboratory tests
Increased white blood cell count and erythrocyte sedimentation
rate
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33. Grading of Crohn's disease
Asymptomatic remission : CDAI <150
Asymptomatic either spontaneously or after medical or surgical intervention.
(but not on steroids)
Mild to moderate: Crohn disease CDAI 150-220 –
Ambulatory patients able to tolerate an oral diet
Have no dehydration, toxicity, abdominal tenderness, mass,
obstruction, or >10 percent weight loss.
Moderate to severe Crohn disease : CDAI 220-45
Failed treatment for mild to moderate disease or
Have prominent symptoms such as fever, weight loss, abdominal pain and
tenderness, intermittent nausea or vomiting, or anemia.
Severe-fulminant disease : CDAI >450
Persisting symptoms despite conventional glucocorticoids or biologic agents
as outpatients, or individuals presenting with high fevers, persistent
vomiting, intestinal obstruction, significant peritoneal signs, cachexia, or
evidence of an abscess
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34. CDAI calculator
Patient reported stool pattern
Average number of liquid or soft stools per day over seven days (14 points per
stool)
Using diphenoxylate or loperimide for diarrhea (30 points)
Average abdominal pain rating over seven days
None (0 points)
Mild pain (35 points)
Moderate pain (70 points)
Severe pain (105 points)
General well being each day over seven days
Well (0 points)
Slightly below average (49 points)
Poor (98 points)
Very poor (147 points)
Terrible (196 points)
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35. CDAI calculator
Complications
Arthritis or arthralgia (20 points)
Iritis or uveitis (20 points)
Erythema nodosum, pyoderma gangrenosum or aphthous stomatitis (20
points)
Anal fissure, fistula or abcess (20 points)
Other fistula (20 points)
Temperature over 100 °F (37.8 °C) in the last week (20 points)
Finding of an abdominal mass
No mass (0 points)
Possible mass (20 points)
Definite mass (50 points)
Anemia and weight change
Absolute deviation of hematocrit from 47% in males or 42% in
females (6 points per percent deviation)
Percentage deviation from standard weight (1 point for each percent
deviation)
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37. Summary of differences in CD &UC
Clinical Feature
Crohn's Disease
Ulcerative Colitis
Malaise, fever
Common
Uncommon
Rectal bleeding
Common
Common
Abdominal tenderness
Common
May be present
Abdominal mass
Common
Absent
Abdominal pain
Common
Unusual
Abdominal wall and
internal fistulas
Common
Absent
Distribution
Discontinuous Mouth to
anus
Continuous
(L.I and Rectum)
Aphthous or linear ulcers
Common
Rare
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38. Summary of differences in CD &UC
Pathologic Feature
Crohn's Disease
Ulcerative Colitis
Rectal involvement
Rare
Common
Ileal involvement
Very common
Rare
Strictures
Common
Rare
Fistulas
Common
Rare
Transmural involvement
Common
Rare
Crypt abscesses
Rare
Very common
Granulomas
Common
Rare
Linear clefts
Common
Rare
Cobblestone appearance
Common
Absent
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41. Goals ofof acute inflammatory processes,
Therapy
1. Resolution
2. Resolution of complications if present(e.g., fistulas,
abscesses),
3. Relief in systemic manifestations (e.g., arthritis),
4. Maintenance of remission from acute
inflammation,
5. Surgical palliation or cure.
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42. General Measures
Alterations to diet
Some of the dietary changes that may be appropriate for a person with
IBD include:
Low fibre diet –
to ease diarrhoea and reduce abdominal cramping. Particularly when a
narrowed small intestine
Low fat diet
Low lactose diet - the milk sugar lactose is broken down by the
enzyme lactase, commonly found in the lining of the small
intestine. Patient of Crohn's disease may lack this enzyme,
Liquid diet - a person with severe Crohn's disease may need a
nutritionally balanced liquid diet.
Plenty of water - people with IBD need to drink plenty of fluids to
prevent dehydration.
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43. Vitamins and Mineral Supplement
A patient on a low fibre diet may need vitamin C and
folic acid supplementation because they don't
consume enough fruit and vegetables.
A patient with Crohn's disease who experiences
steatorrhoea may need calcium and magnesium
supplements.
Almost all children with IBD to take supplements to
lower risk of impaired growth and development.
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44. Drug T/M of U.C: To induce remission
Mild to Moderate Disease
The first line of drug any one of the following
Oral sulfasalazine or an oral mesalamine or, or topical
mesalamine or steroids for distal disease
Dose 4 g/day, up to 8 g/day of sulfasalazine to control active
disease ( start with 500 mg/day and increase gradually
Oral mesalamine alternative but not more effective than
Sulfazalazine
If not responsive: STEROIDS:
Are equally effective as sulfasalazine, but effect appear sooner.
Prednisone up to 1 mg/kg/day or 40 to 60 mg daily
Rectally administered steroids or mesalamine can be used as initial
therapy for patients with ulcerative proctitis or distal colitis.
Nicotine Transdermal improves symptoms of patients with mild to
moderate active ulcerative colitis in daily doses of 15 to 25 mg.
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45. T/M: Severe U.C.: Induce remission
Hospitalization
Steroids: help to avoid colectomy in severe UC
Hydrocortisone 100 mg iv 6-8 hourly till remission
Shift to oral prednisolone ( 1mg/kg/day)after remission
(prednisolone)
All patients before surgery should be given trial of
Steroids
If refractory to steroids, continuous IV infusion of
cyclosporine (4 mg/kg/day)
If no response :Surgical procedures may be
required.
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46. Maintenance of Remission
Sulfasalazine : 2 g/day orally
Mesalamine derivatives, can be used, but not as effective
as sulfasalazine.
No role of steroids: withdraw gradually after remission
is induced (over 3 to 4 weeks)
Azathioprine: effective in preventing relapse of ulcerative
colitis for periods exceeding 4 years. However, 3 to 6
months may be required for beneficial effect
Infliximab: continue if patient initially responded to it : 5
mg/kg every 8 weeks as maintenance therapy is an
alternative for steroid dependent patients
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50. Crohn’s Disease: Induce Remission
Main Drugs:
Sulfasalazine, mesalamine derivatives, or steroids,
Other choices, according to situation
Azathioprine, mercaptopurine, methotrexate,
infliximab,
Metronidazole, Ciprofloxacin??
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51. Crohn’s Disease: Induce Remission
If Colon is Involved:
Sulfasalazine is more effective Why??
If Ileal disease:
Mesalamine derivatives (Pentasa or Asacol)
more effective. why??
Steroids
When active and severe disease
Unresponsive to amino-salicylates.
Budesonide first-line option for patients with mild to
moderate ileal or right-sided disease.
Systemic steroids induce remission in up to 70% of patients
and should be reserved for patients with moderate to severe
disease who have failed aminosalicylates or budesonide.
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52. Crohn’s Disease: Induce remission
Metronidazole orally up to 20 mg/kg/day
In patients with colonic or ileocolonic involvement
The combination with ciprofloxacin is efficacious in some patients.
Immunosuppressive agents: azathioprine and mercaptopurine
For those not achieving adequate response to standard therapy,
To reduce steroid doses when toxic doses are required.
Dose: azathioprine is 2 to 3 mg/kg/day and mercaptopurin: 1 to 1.5
mg/kg/day for
Duration: Up to 3 to 4 months may be required to observe a response.
Starting doses are typically 50 mg/day and increased at 2-week intervals
while
Monitoring:
Complete blood count
Determine TPMT or TPMT before start of therapy Patients deficient in
thiopurine S-methyltransferase (TPMT) are at greater risk of bone
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53. Crohn’s Disease: Induce remission
Cyclosporine
Symptomatic and severe perianal or cutaneous fistulas.
An oral dose of 7.9 mg/kg/day. However, toxic
Monitor dose by whole-blood concentrations.
Methotrexate,
5 to 25 mg iv/week, for induction of remission and maintenance
therapy.
The risks bone marrow suppression, hepatotoxicity,
and pulmonary toxicity
Infliximab moderate to severe active disease
failing immunosuppressive therapy,
Corticosteroid dependent,
Treatment of fistulizing disease.
Dose: 5 mg/kg infusion every day for 8 weeks.
Additional doses at2 and 6 weeks following the initial dose results
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54. Crohn’s Disease: Induce remission
Adalimumab
effective in 54% of patients with moderate to severe
disease who have lost response to infliximab.
Dosage is 160 mg subcutaneously initially, followed by
80 mg subcutaneously at week 2, with subsequent doses
of 40 mg subcutaneously every other week
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55. Maintain Remission
Difficult than that in U.C.
Sulfasalazine and oral mesalamine
derivatives are effective
Steroids have no place
Azathioprine, mercaptopurine,
methotrexate, infliximab, and
adalimumab are effective in maintaining
remission in selected patients Crohn’s
disease.
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57. Rationale of Antibacterials
Based upon a large body of evidence demonstrating
that luminal bacteria have an important role in the
pathogenesis of IBD
Decreasing the concentrations of bacteria and fungi in
the gut lumen
Altering the composition of the intestinal microbiota to
favor beneficial bacteria
Decreasing bacterial tissue invasion and treating
microabscesses
Decreasing bacterial translocation and systemic
dissemination
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58. Fulminant Colitis and Toxic Megacolon
Acute fulminant colitis : severe diarrhea with abdominal
pain, bleeding, fever, sepsis, electrolyte disturbances, and
dehydration.
Toxic mega colon: in 1%-2% of patients with UC; the
colon becomes atonic and modestly dilates, systemic
toxicity is the dominant feature.
Treatment
Keep NPO, with NG suction if there is evidence of small-bowel
ileus.
Treat dehydration and electrolyte disturbances
Anticholinergic and opioid medication should be discontinued.
Intensive therapy with IV corticosteroids (hydrocortisone, 100 mg
IV q6h or equivalent)
Broad-spectrum antimicrobials: Metro+Ciprofloxacin
Surgery: Urgent total colectomy
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Clinical deterioration/lack of improvement despite 7-10 days of management,
Evidence of bowel perforation, or peritoneal signs
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59. Pregnancy & IBD
Pregnancies are well managed in patients with these
diseases.
Same indications for medical and surgical treatment
First attack:
standard treatment with sulfasalazine or steroids
Folic acid supplementation, 1 mg twice daily,
Metronidazole or methotrexate should not be used
during pregnancy.
Azathioprine and mercaptopurine may be associated
with fetal deformities.
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60. Evaluation of Therapeutic Outcomes:C.D
Crohn Disease Activity Index
EIGHT parameters:The Crohn’s Disease Activity Index
is used for evaluation of patients during clinical trials.
1) number of stools in the past 7 days
2) sum of abdominal pain ratings from the past 7 days
3) rating of general well-being in the past 7 days
4) use of antidiarrheals
5) body weight
6) hematocrit
7) finding of abdominal mass
8) a sum of symptoms present in the past week.
Elements of this index provide a guide to assess the effectiveness
of treatment regimens.
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61. Evaluation of Therapeutic Outcomes: U.C
Look for:
Stool frequency
Presence of blood in the stool
Mucosal appearance (from endoscopy)
Physician’s global assessment based on physical
examination, endoscopy, and laboratory data.
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63. Surgery in IBD
For ulcerative colitis, colectomy may be performed:
If disease uncontrolled by maximum medical therapy
Complications of the disease such as colonic
perforation, toxic dilatation (megacolon), uncontrolled
colonic hemorrhage, or colonic strictures.
In Crohn’s disease surgery is reserved for
The complicated disease.
But there is a high recurrence rate of Crohn’s disease
after surgery.
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64. • Objectives for this section:
• After completion of this section, the student will be able to
•
•
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Select rationalizd therapy
Know the adverse effect for follow up evaluation
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65. Drug used in Treatment of IBD
5-Aminosalicylic acid
(ASA) compounds
Sulfasalazine
Newer 5-ASA preparations
lack the sulfa moiety
Mesalamine (5-ASA)
Olsalazine
Glucocorticoids
Prednisone
Budesonide
Hydrocortisone
Antibiotics
Metronidazole.
Ciprofloxacin
Sulfamethoxazole-trimethoprim
Immunomodulating agents
6-Mercaptopurine
Azathioprine
Methotrexate
cyclosporine
Infliximab
Sargramostim
recombinant granulocyte-macrophage colony-stimulating
factor
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66. Sulfasalazine
Reaches the colon intact, where it is metabolized into 5-ASA and a
sulfa-pyridine.
Used for colonic disease (UC and Crohn's disease limited to the colon),
either as initial therapy (0.5 g PO bid, increased as tolerated to 0.5--1.5
g PO qid) or to maintain remission (1 g PO bid to qid).
Adverse effects: Mainly caused by the sulfa pyridine moiety
Headache, nausea, vomiting, and abdominal pain;
a reduction in dose may be beneficial.
Can cause drug induced pancreatitis
Hypersensitivity reactions are less common and include skin
rash, fever, agranulocytosis, hepatotoxicity, and aplastic anemia.
Reversible reduction in sperm counts can be seen in males.
Paradoxic exacerbation of colitis is a rare adverse effect.
Folic acid supplementation is recommended, as sulfasalazine impairs
folate absorption.
STUDY ASSIGNEMENT: Mechanism of action of ASA’s (Ref:Katzung
Pharmacology,
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67. Newer 5-ASA preparations
Mesalamine (5-ASA) is available in several formulations. An oral
preparation released at pH >7 (Asacol, 800 to 1,600 mg PO tid) is
useful in UC as well as ileocecal/colonic Crohn's disease.
Balsalazide (2.25 g PO tid for active disease, 1.5 g PO bid for
maintenance), is cleaved by colonic bacteria to mesalamine and an
inert carrier molecule and is useful for colonic inflammation
Olsalazine is a 5-ASA dimer that is cleaved by bacteria in the colon
and can be used in UC and Crohn's colitis. Diarrhea is a major side
effect and can limit its use
Adverse effectsRare hypersensitivity reactions occur and include
pneumonitis, pancreatitis, hepatitis, and nephritis.
.
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68. Glucocorticoids-1
Beneficial in inducing remission of active UC and
Crohn's disease.
Can be used concurrently with other anti-inflammatory agents in
moderate to severe disease,
In exacerbations of the disease
Extra colonic manifestations of inflammatory bowel disease
ocular lesions,
skin disease,
peripheral arthritis
Not recommended for mild disease
Not recommended for maintenance therapy
Dose:
Prednisone is 40-60 mg orally, once a day in the morning. can be reduced
by 10 mg every 5-10 days and tapered off in 3-6 weeks
Methylprednisolone, 20-40 mg INTRAVENOUS daily to bid, up to 1
mg/kg/d) In
severe disease
in Patients who cannot tolerate oral medication
brief periods;
higher doses are used in refractory disease
Budesonide (9 mg/d) may have less systemic side effects compared to
glucocorticoids when used for mild to moderate ileocolonic Crohn's disease
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69.
70. Immunosuppressive agents
6-Mercaptopurine, and Azathioprine,
Cause preferential suppression of T-cell activation and antigen
recognition.
Are used orally in doses of 1-1.5 mg/kg body weight daily
More favorable side effect profiles than do glucocorticoids
Are used as steroid-sparing agents in severe or refractory inflammatory
bowel disease (IBD).
Response after up to 1-2 months.
Adverse effects
Reversible bone marrow suppression,
Pancreatitis,
Allergic reactions
Methotrexate (15-25 mg IM or PO weekly)
used as a steroid-sparing agent in Crohn's disease.
Adverse effects
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hepatic fibrosis,
bone marrow suppression, alopecia, pneumonitis, allergic reactions, and
teratogenicity
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71. Immunosuppressive agents
Cyclosporine has been used INTRAVENOUSLY in
refractory cases of UC. The benefit is temporary.
Adverse effects
nephrotoxicity,
hepatotoxicity,
hypertrichosis,
seizures,
lymphoproliferative disorders
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72. Infliximab
Monoclonal antibody against tumor necrosis factor-Î
induces inflammatory cell lysis by binding to tumor necrosis factor
receptors on the cell surface.
Infliximab is used for
fistulous Crohn's disease,
refractory inflammatory-type Crohn's disease unresponsive to
conventional therapy,
severe ulcerative colitis.
Dose: IV infusions of 5 mg/kg)
Induction regimens typically consist of doses at 0, 2, and 6 weeks, with
maintenance doses every 8 weeks.
Adverse Effects:
Congestive heart failure may worsen after therapy.
Sepsis and reactivation of latent tuberculosis or histoplasmosis may occur;
a tuberculin test may be indicated to evaluate for latent tuberculosis.
Serious infusion reactions may occur, and constant monitoring is essential
during infusion.
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73. Antibacterial Agents
Metronidazole (250-500 mg PO tid)
first-line agent or adjunctive therapy in mild to moderate Crohn's
disease.
Peripheral neuropathy is a concern with long-term use.
Ciprofloxacin (500 mg PO bid) has also been used in Crohn's
disease.
The two agents can be used concurrently in perianal
Crohn's disease for prolonged periods with good results.
An alternative agent is Co-trimoxazole
03/05/14
Dr Afzal Haq Asif
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