Inflammatory conditions of colon and small intestine. The major types are ulcerative colitis (UC) and Crohn's disease (CD). They can cause malabsorption and anal fissure.
Symptoms: cramping, bloody diarrhea, fever and weight loss
UC: affects only rectum and colon with superficial ulceration, blood in the stool (in contrast to CD where the ulcer can be deep), mucosal lesions (in UC are more superficial than those in CD, which are more transmural).
CD: any part of GI tract, 2/3 case are ileum which is the last part of small intestine, no blood in the stool, only inflammation (The inflammation in CD occurs in a segmented or cobblestone pattern, while in UC it occurs in a more continuous fashion), fistula formation.
Treatment
Antidiarrheals in simpler cases: Loperamide (Imodium) 2 mg after each loose stool, max 8 doses/day
Antispasmodic: The most common one is dicyclomine (Bentyl) 10mg AC +HS, or hyoscyamine (Levsin,Levbid, Levsinex): before meals
Oral steroid: For acute flare-ups.
Aminosalicylates (salfasalazine, mesalamine): for more moderate symptoms to control inflammation.
Immunosuppressive agents: in moderate-severe cases
TNF-blockers: in severe conditions.
Rifaximin (Xifaxan): indicated for GI infection.
Steroid
Drugs: Budesonide (Entocort)
A 3A4 substrate.
Long term effects (apply to all steroids): adrenal suppression, Cushing's syndrome, impaired wound healing, HTN, hyperglycemia, cataracts, osteoporosis.
Cautious about sulfa (Sulfasalazine) or salicylate allergy
DI: avoid concurrent use of antacid, H2RA, PPI
Sulfasalazine: May cause yellow-orange discoloration of skin/urine, impair folate absorption; Take with food and 8oz water to prevent crystalluria.
Balsalazide: Prodrug of mesalamine.
Rectal or enema are 1st line for UC mild-mod distal disease.
Immunosuppressive agent (AZA, 6-MP, MTX)
Azathioprine (Imuran) - AZA
Purine antimetabolite
BBW: immunosuppression, increase risk of neoplasia, hepatotoxicity.
Methotrexate (Rheumatrex) - MTX
5 - 20mg Q-wk
Antidote: leucovorin
Many BBW: liver, renal, pneumonitis, stomatitis, dermatologic reactions.
TNF blockers (Monoclonal antibody against TNF)
Drugs (IV only): Infliximab (Remicade)
BBW: serious infection (TB, opportunistic, fungal). All patients should be evaluated for TB before starting
SE: infusion reaction, HF exacerbation, bone marrow suppression, hepatitis.
If not working, then try: Humira (adalimumab), Cimzia (certolizumab), Tsyabri (natalizumab, must enroll TOUCH program)
Natural products
Stimulant laxatives: Senna, Cascara.
Bulk-forming fiber: psyllium (Metamucil), well tolerated.
Peppermint oil, chamomile tea: antispasmodic.
Probiotic: help reduce abdominal pain, bloating, urgency.
Quiz
Infliximab is the generic name for which of the following medications?
Imuran
Colazal
Humira
Neoral
Remicade
A patient with UC has a history of anaphylaxis when taking trimethoprim/sulfamethoxazole. Which of the following medications would be safe to use for the treatment of UC in this patient? (Select ALL that apply.)
Mesalamine
Budesonide
Methotrexate
adalimumab
Sulfasalazine
Which of the following characteristics occur more often with UC than CD?
Confinement of the disease to the colon and rectum
Fistula formation
Cobblestone pattern of inflammation
Transmural lesion in the GI tract
Systemic complications
Which of the following baseline tests should be performed before initiating certolizumab therapy for a patient with CD?
PPD
Brain MRI
LFT
Serum creatinine
Uric acid
Which of the following supplements may be needed in a patient taking chronic sulfasalazine therapy?
Calcium + D
Folic acid
Iron
Vitamin B12
Vitamin C
Answers
Infliximab is the generic name for Remicade. Azathioprine (Imuran), Balsalazide (Colazal), Adalimumab (Humira), Cyclosporine (Neoral).
Sulfasalazine is a sulfa derivative and should be avoided in patients with sulfa allergy (e.g., trimethoprim/sulfamethoxazole). All other choices are not sulfa derivatives and could be safely used.
UC is more often confined to the colon and rectum, whereas CD can affect any part of the GI tract from the mouth to the anus. Fistulas are more likely to develop in patients with CD as opposed to UC. The inflammation in CD occurs in a segmented or cobblestone pattern, while it presents a more continuous fashion in UC. The mucosal lesions in UC are more superficial, whereas in CD are more transmural. Systemic complications can happen with either UC or CD.
Before starting therapy with certolizumab, patients should be evaluated for TB with a PPD. Cases of reactivation of TB or new TB infections have been reported in patients receiving TNF-blockers; patients are at increased risk for developing serious infections. Certolizumab has not been associated with PML (life-threatening), so there is no need to perform a brain MRI (a baseline brain MRI should be performed with natalizumab). Certolizumab is not associated with hepatotoxicity or nephrotoxicity and does not affect uric acid levels.
