Inflammatory bowel disease (ibd) drug information page

Inflammatory Bowel DiseaseBy : Dr. Ibrahim Gomaa’Drug Information page

Inflammatory Bowel Disease

Chron’s disease

Ulcerative Colitis

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

Epidemiology

Most commonly in patients between 15-40

years

More common in females

Etiology

Immunology

Genetic factors

Diet

Infective agents

There

is no

specifi

c cau

se of

IBD

EtiologyImmunology

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

There

is no

specifi

c cau

se of

IBD

EtiologyGenetic factors

genetic incidence hasnot been

established although 10 % of patients have 1st degree relative to disease

There

is no

specifi

c cau

se of

IBD

EtiologyDiet

Patients with chron’s disease :

Increase intake of sweet , fatty or

refines food

Decrease intake of fructose , fruits , water , K , Mg &

vitamin C

There

is no

specifi

c cau

se of

IBD

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

There

is no

specifi

c cau

se of

IBD

Clinical Manifestation

Anorexia&

Wieght loss

Nausea DiarrheaAbdominal

painAbdominal tenderness

Depending on the severity & site of activity so the patient can present with systemic &

intestinal symptoms

Most Significant

Non Specific

Investigation

Endoscopy

Radiology

Histology

Blood test

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

Standard

test

Radiology

Double contrast barium enema

Histology

Differentiate between small bowel & colonic lesions wrongly labeled chron’s disease

Blood tests

Test for anemia & vitamin B12 deficiency

Test for up regulation of immune system

Ulcerative Colitis

Disease of colon characterized by

ulcers & inflammation in

colon

Chronic relapsing inflammatory

disease affecting colonic & rectal

mucosa

AffectingOnly rectal mucosa =

proctitisRectum & sigmoid

colon = asproctosigmoiditis

Other organs = colitis

Epidemiology

More common in non smokers

No variation between men & women or in

socioeconomic groups

Etiology

Genetic factors

Environmental factors

There

is no

specifi

c cau

se of

IBD

Etiology

Genetic factors

Familial or genetic incidence of ulcerative colitis has wide variation from

1-16 %

There

is no

specifi

c cau

se of

IBD

EtiologyEnvironmental

factors

Infective agents

There

is no

specifi

c cau

se of

IBD

Diet Psychological stress


Abdominal pain

Diarrhea mixed with

blood & mucous

Elderly suffering from

proctosigmoiditis may complain of

constipation

Patients complain from systemic & intestinal symptomsProctitis = Only intestinal symptoms

Proctosigmoiditis = More severe symptoms


Determination of severity of ulcerative colitis quantitavily by monitoring:

The number of bowel motions

Macroscopic appearance of blood in

stools

Anemia Erythrocyte sedimentation

rate

Investigation

Endoscopy

Radiology

Laboratory tests

Endoscopy

Sigmoiscopy

Used to confirm diagnosis of ulcerative colitis

Radiology

Double contrast barium enema

Laboratory tests

Microbiological examination of stool

Haematological & biochemical values

High WBC countsIron deficiency anemia

Low ESR Low serum albumin

May provide evidence of infection as a cause of colonic

inflammation

Treatment

Non- Pharmacological

Pharmacological

Non- Pharmacological

No specific dietary restrictions are recommended for patients with IBD

Nutritional strategies :in patients with long-standing

Administration of vitamin B12

& folic acid

Administrtion of fat-soluble

vitamins, &iron

In severe cases, enteral or parenteral

nutrition may be needed to

achieve adequate

caloric intake

Patients should receive a baseline

bone density measurement

priorto receiving

corticosteroids

Vitamin D & calcium & oral biphosphonate

should be used in all patients

receiving long-term

corticosteroids.

Drug treatment

Corticosteroids

Aminosalicylates

Immuno suppressants

Cyclosporin

Other agents

Corticosteroids

Eg

Predinoslone

Steroid of choice as it can be used

orally , rectally & parentrally in

emergency Adverse

effects

CataractsSkin

AtrophyHyper -tension

Hyper glycemia

Adrenal suppression

Osteo-porosis

increased risk of

infection

Increased when dose < 40mg/day

Avoided by

Alternate day regimen

Steroid sparing properties of Azathioprone

Corticosteroids

Eg

Predinoslone

Steroid of choice as it can be used

orally , rectally & parentrally in

emergency

Dose :20–60 mg orally or IVUsed up to 2 weeks

Corticosteroids

Eg

Hydrocortisone

300 mg IV in three divided doses100 mg rectally at

bedtime90 mg rectally once or

twice daily

25–50 mg rectally twice daily

Corticosteroids

Eg

Budesonide

Induction: 9 mg orallyMaintenance: 6 mg orally

May prevent some long-term adverse effects in patients who

have steroid-dependent IBD.

Amino salicylates

Eg

SulfasalazineThe most effective in

maintaining remission in ulcerative colitis

( Anti-inflammatory )

Adverse effects

Nausea &

Vomiting

Haemo-lytic

anemiaHeadache Skin rash

Hepatic & pulmonary dysfunction

Aplastic anemia

Azo- spermia

Dose related Idiosyncratic

Amino salicylates

Eg

Sulfasalazine

DoseMaintain remission : 2-4 g / day

Acute attacks : 4-8 g / day

The most effective in maintaining remission in

ulcerative colitis


Amino salicylates

Eg

Mesalaszine

DoseDelayed release tablets : 1.6–4.8 g

Active component of sulfasalazine


Amino salicylates

Eg

Mesalaszine

Suppositories: 1 g

Active component of sulfasalazine


Sachets : 1g

Dose:

Amino salicylates

Eg

MesalamineActive component of

sulfasalazine


Dose:Enemas : 4 g

Amino salicylates

Eg

OlsalazineUses two Mesalamine

molecules linked together


Dose:Capsules: 1–3 g

Amino salicylates

Eg

Balsalazide


Dose:Capsules : 2–6.75 g

Used in patients unresponsive to steroid & amino salicylates

Immuno suppressants

Eg

Azathioprine

Dose:1.5–2.5 mg/kg per day orally

Inhibit purine biosynthesis & reduce IBD-associated GI

inflammation

Most useful fo

r maintaining

remission of IB

D or reducin

g

the need for lo

ng-term

use

of cortico

steroids


Immuno suppressants

Eg6-

Mercaptopurine

Most useful fo

r maintaining

remission of IB

D or reducin

g

the need for lo

ng-term

use

of cortico

steroids

Dose:1.5–2.5 mg/kg per day orally

Active form of Azathioprine


Immuno suppressants

Eg

MethotrexateMost

useful for m

aintaining

remission of IB

D or reducin

g

the need for lo

ng-term

use

of cortico

steroids

Dose:15–25 mg weekly

(IM/SC/orally)


Immuno suppressants

Eg

CyclosporineMost

useful for m

aintaining

remission of IB

D or reducin

g

the need for lo

ng-term

use

of cortico

steroids

Dose:4 mg/kg per day

Effective in patients refractory to cenventional drug therapy

Immuno suppressants

Eg

Infliximab

Adverse effects

Intravenous administration

Fever Chest Pain

Hypo-tension

Dyspnea

Associated with

reactivation of serious infections

Exa- cerbation of heart failure

infusion-related reactions

Effective in patients whose conventional therapy failed

Dis advantages

Significant drug cost Potential for adverse effects

Immuno suppressants

Eg

Infliximab Effective in patients whose conventional therapy failed

Other agents

Eg

Metronidazole

Dose:Adults : 500mg 3times for 7-10 days.

Children : 125-250mg./8Hrs.for 7-10 days.

Used in chrons disease & maybe effective in U.colitis

Other agents

Eg

Antibiotics

Dose:Adults < 12 yrs : 250 - 500mg / 12 hrs for 7-14 days.

Eg. Ciprofloxacin

For active chrons disease accompained by fever

Other agents

Eg

Antibiotics

Dose:Adults & children: 250 - 1000mg / 6 hrs for 7-14 days.

Eg. Cephazolin


Other agents

Eg

Antibiotics

Dose:Adults : 500 - 1000mg / 6-8 hrs for 5-10 days.Children: 50-100 mg/ 6-8 hrs for 5-10 days.

Eg. Ampicillin


Other agents

Eg

Anti DiarrhealRelief diarrhea symptoms

associated eith IBD

Diphenoxylate LoperamideCodiene

Delay corre

ct diagnosis

because masking

inflammation , infecti

on ,

obstructi

on or colonic

dilatation

Other agents

EgNa

CromoglycateReduce degranulation of mast cells & inhibits passage of Ca

ions across cell membrane

Treatment of IBD in Special Populations

Elderly Patients

Children & Adolescents

Pregnant Women

Elderly Patients

Special consideration should begiven to some of the medications used

CorticosteroidsDiabetes

HypertensionHeart failureOsteoporosis

May

worsen

Amino salicylates Colitis

May

exacerbate

Immuno suppressants

InfliximabUsed In caution with

heart failure

According to Priority

Children & Adolescents

major issue in children with IBD is the risk of growth failure secondary to inadequate nutritional intake

Amino salicylates

Azatioprine & 6-mercaptopurine

viable options for treatment and

maintenance of IBDin pediatric patients

infliximab

Corticosteroidshigher risk for IBD-

associated bone demineralization

According to Priority

Pregnant Women

Amino salicylates

Corticosteroids

Safe to use inpregnancy, but

sulfasalazine is associated with folate malabsorption

Azatioprine & 6-mercaptopurine

infliximab

For active disease not maintenance of remissionAccording to

PriorityCyclosporine

Methotrexate

Minimal risk in pregnant

Abortifacient & contraindicated during

pregnancy

Patient Education

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

Patient Education

Infertility assoiciated with sulphasalazine

so use alternative

aminosalicylates

When considering

treatment with azathioprine or

6-MP, obtain baseline CBC & liver function

tests

Pregnant patients treated with sulfasalazine

should besupplemented

with folic acid 1 mg orally twice

daily

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