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Inflammatory bowel disease (ibd) drug information page

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  • 1. Inflammatory Bowel Disease By : Dr. Ibrahim Gomaa’ Drug Information page
  • 2. Inflammatory Bowel Disease Chron’s disease Ulcerative Colitis
  • 3. Chron’s disease Chronic episodic inflammatory condition of gut affecting entire wall of bowel region involved Affect any part of GIT from lips to anal margin Current treatment is palliative not curatice
  • 4. Epidemiology More common in females Most commonly in patients between 15-40 years
  • 5. Etiology Immunology Genetic factors Diet Infective agents
  • 6. Etiology Immunology Characterized as autoimmune disease Occue when immune system attacked & leading to GIT discomfort by increasing GIT wall inflammation Improvement in nutitional status may improve immune system
  • 7. Etiology Genetic factors genetic incidence hasnot been established although 10 % of patients have 1st degree relative to disease
  • 8. Etiology Diet Patients with chron’s disease : Increase intake of sweet , fatty or refines food Decrease intake of fructose , fruits , water , K , Mg & vitamin C
  • 9. Etiology Infective agents Patholoical similarities between chron’s & TB focus attention on mycobacterium species Have higher fecal counts of aerobic gram –ve rods & gram +ve coccoid rods from cporococcus & peptosterptococcus
  • 10. Clinical Manifestation Depending on the severity & site of activity so the patient can present with systemic & intestinal symptoms Anorexia & Nausea Diarrhea Abdominal pain Wieght loss Most Significant Non Specific Abdominal tenderness
  • 11. Investigation Endoscopy Radiology Histology Blood test
  • 12. Endoscopy Colonoscopy Most reliable diagnosis as it allow direct visualization of colon & terminal ileum Finding of patchy distribution of disease with involvement of colon or ileum but not rectum indicate Chron’s disease
  • 13. Radiology Double contrast barium enema
  • 14. Histology Differentiate between small bowel & colonic lesions wrongly labeled chron’s disease
  • 15. Blood tests Test for up regulation of immune system Test for anemia & vitamin B12 deficiency
  • 16. Ulcerative Colitis Disease of colon characterized by ulcers & inflammation in colon Chronic relapsing inflammatory disease affecting colonic & rectal mucosa Affecting Only rectal mucosa = proctitis Rectum & sigmoid colon = asproctosigmoiditis Other organs = colitis
  • 17. Epidemiology No variation between men & women or in socioeconomic groups More common in non smokers
  • 18. Etiology Genetic factors Environmental factors
  • 19. Etiology Genetic factors Familial or genetic incidence of ulcerative colitis has wide variation from 1-16 %
  • 20. Etiology Environmental factors Infective agents Diet Psychological stress
  • 21. Clinical Manifestation Patients complain from systemic & intestinal symptoms Proctitis = Only intestinal symptoms Proctosigmoiditis = More severe symptoms Abdominal pain Diarrhea mixed with blood & mucous Elderly suffering from proctosigmoiditis may complain of constipation
  • 22. Clinical Manifestation Determination of severity of ulcerative colitis quantitavily by monitoring: The number of bowel motions Macroscopic appearance of blood in stools Anemia Erythrocyte sedimentation rate
  • 23. Investigation Endoscopy Radiology Laboratory tests
  • 24. Endoscopy Sigmoiscopy Used to confirm diagnosis of ulcerative colitis
  • 25. Radiology Double contrast barium enema
  • 26. Laboratory tests Haematological & biochemical values Iron deficiency anemia Low ESR Microbiological examination of stool High WBC counts Low serum albumin May provide evidence of infection as a cause of colonic inflammation
  • 27. Treatment NonPharmacological Pharmacological
  • 28. NonPharmacological No specific dietary restrictions are recommended for patients with IBD Nutritional strategies : in patients with long-standing Administratio n of vitamin B12 & folic acid Administration of fat-soluble vitamins, &iro n In severe cases, enteral or parenteral nutrition may be needed to achieve adequate caloric intake Patients should receive a baseline bone density measurement prior to receiving corticosteroids Vitamin D & calcium & oral biphosphonate should be used in all patients receiving longterm corticosteroids.
  • 29. Drug treatment Corticosteroids Aminosalicylates Immuno suppressants Cyclosporin Other agents
  • 30. Corticosteroids Eg Predinoslone Increased when dose 40mg/day Cataracts Skin Atrophy Steroid of choice as it can be used orally , rectally & parentrally in emergency Adverse effects Hyper tension Hyper glycemia Adrenal suppression Avoided by Alternate day regimen Steroid sparing properties of Azathioprone Osteoporosis increased risk of infection
  • 31. Corticosteroids Eg Predinoslone Dose : 20–60 mg orally or IV Used up to 2 weeks Steroid of choice as it can be used orally , rectally & parentrally in emergency
  • 32. Corticosteroids Eg Hydrocortisone 300 mg IV in three divided doses 100 mg rectally at bedtime 25–50 mg rectally twice daily 90 mg rectally once or twice daily
  • 33. Corticosteroids Eg Budesonide Induction: 9 mg orally Maintenance: 6 mg orally May prevent some long-term adverse effects in patients who have steroid-dependent IBD.
  • 34. Amino salicylates ( Anti-inflammatory ) Eg The most effective in maintaining remission in ulcerative colitis Sulfasalazine Adverse effects Nausea & Vomiting Haemolytic anemia Headache Dose related Skin rash Hepatic & pulmonary dysfunction Aplastic anemia Idiosyncratic Azospermia
  • 35. Amino salicylates ( Anti-inflammatory ) Eg Sulfasalazine Dose Maintain remission : 2-4 g / day Acute attacks : 4-8 g / day The most effective in maintaining remission in ulcerative colitis
  • 36. Amino salicylates ( Anti-inflammatory ) Eg Mesalaszine Dose Delayed release tablets : 1.6–4.8 g Active component of sulfasalazine
  • 37. Amino salicylates ( Anti-inflammatory ) Eg Mesalaszine Active component of sulfasalazine Dose: Suppositories: 1 g Sachets : 1g
  • 38. Amino salicylates ( Anti-inflammatory ) Eg Mesalamine Dose: Enemas : 4 g Active component of sulfasalazine
  • 39. Amino salicylates ( Anti-inflammatory ) Eg Olsalazine Dose: Capsules: 1–3 g Uses two Mesalamine molecules linked together
  • 40. Amino salicylates Eg Balsalazide Dose: Capsules : 2–6.75 g ( Anti-inflammatory )
  • 41. Immuno suppressants Used in patients unresponsive to steroid & amino salicylates Eg Azathioprine Dose: 1.5–2.5 mg/kg per day orally Inhibit purine biosynthesis & reduce IBD-associated GI inflammation
  • 42. Immuno suppressants Used in patients unresponsive to steroid & amino salicylates Eg 6Mercaptopurine Dose: 1.5–2.5 mg/kg per day orally Active form of Azathioprine
  • 43. Immuno suppressants Eg Methotrexate Dose: 15–25 mg weekly (IM/SC/orally) Used in patients unresponsive to steroid & amino salicylates
  • 44. Immuno suppressants Used in patients unresponsive to steroid & amino salicylates Eg Cyclosporine Dose: 4 mg/kg per day Effective in patients refractory to cenventional drug therapy
  • 45. Immuno suppressants Eg Infliximab Effective in patients whose conventional therapy failed Dis advantages Intravenous administration Significant drug cost Potential for adverse effects Adverse effects Fever Chest Pain Hypotension Dyspnea infusion-related reactions Associated with reactivation of serious infections Exacerbation of heart failure
  • 46. Immuno suppressants Eg Infliximab Effective in patients whose conventional therapy failed
  • 47. Other agents Eg Metronidazole Used in chrons disease & maybe effective in U.colitis Dose: Adults : 500mg 3times for 7-10 days.  Children : 125-250mg./8Hrs.for 7-10 days.
  • 48. Other agents Eg Antibiotics For active chrons disease accompained by fever Eg. Ciprofloxacin Adults Dose: 12 yrs : 250 - 500mg / 12 hrs for 7-14 days.
  • 49. Other agents Eg Antibiotics For active chrons disease accompained by fever Eg. Cephazolin Dose: Adults & children: 250 - 1000mg / 6 hrs for 7-14 days.
  • 50. Other agents Eg Antibiotics For active chrons disease accompained by fever Eg. Ampicillin Dose: Adults : 500 - 1000mg / 6-8 hrs for 5-10 days. Children: 50-100 mg/ 6-8 hrs for 5-10 days.
  • 51. Other agents Eg Anti Diarrheal Codiene Diphenoxylate Relief diarrhea symptoms associated eith IBD Loperamide
  • 52. Other agents Eg Na Cromoglycate Reduce degranulation of mast cells & inhibits passage of Ca ions across cell membrane
  • 53. Treatment of IBD in Special Populations Elderly Patients Children & Adolescents Pregnant Women
  • 54. Elderly Patients Special consideration should be given to some of the medications used May Corticosteroids According to Priority Amino salicylates worsen May exacerbate Diabetes Hypertension Heart failure Osteoporosis Colitis Immuno suppressants Used Infliximab In caution with heart failure
  • 55. Children & Adolescents major issue in children with IBD is the risk of growth failure secondary to inadequate nutritional intake Amino salicylates According to Priority Azatioprine & 6-mercaptopurine viable options for treatment and maintenance of IBD in pediatric patients infliximab Corticosteroids higher risk for IBDassociated bone demineralization
  • 56. Pregnant Women Amino salicylates According to Priority Safe to use in pregnancy, but sulfasalazine is associated with folate malabsorption Corticosteroids For active disease not maintenance of remission Azatioprine & 6-mercaptopurine Cyclosporine infliximab Methotrexate Minimal risk in pregnant Abortifacient & contraindicated during pregnancy
  • 57. Patient Education
  • 58. Patient Education Patients taking steroids must be issied with steroid card If symptoms recur patient should hhave written instructions to increase the dose of current therapy Effective home treatment of proctitis is important
  • 59. Patient Education Infertility assoiciated with sulphasalazine so use alternative aminosalicylates Pregnant patients treated with sulfasalazine should be supplemented with folic acid 1 mg orally twice daily When considering treatment with azathioprine or 6-MP, obtain baseline CBC & liver function tests