IBD III

Question 1

Mild-Moderate Active UC

• left sided disease within reach of ___
• proctitis within reach of ___
• extensive disease, pancolitis (i.e.,
  proximal disease, beyond splenic
  flexure) requires ___ tx

Answer 1

• enemas
• suppositories
• systemic

Question 2

Mild-Moderate Active UC

oral and/or topical ASAs
- if extensive disease: ___ 5-ASA
- left sided disease, topical mesalamine ___ (1 g/day)
- proctitis: mesalamine ___ (1 g/day)
- combo of ___ and ___ may be more effective for pts with left-sided/extensive disease

Answer 2

• oral
• enema
• suppository
• oral, topical

Question 3

Mild-Moderate Active UC

if oral tx:
- ___ derivatives better tolerated than ___
- sulfasalazine: 2-6 g/day in divided doses
- mesalamine derivatives: 2-3 g/day

consider compliance, convenience, financial resources in product choice
* once daily dosing preferred

Answer 3

• mesalamine, sulfasalazine

Question 4

Mild-Moderate Active UC

if unresponsive to 5-ASA, can consider changing ___
* if unresponsive to standard-dose 5-ASA or moderate disease activity, AGA recommends high-dose ___ (> __ g/day) plus rectal ___

Answer 4

formulation
mesalamine, 3, mesalamine

Question 5

Mild-Moderate Active UC

CR ___ is alternative (AGA also now
includes ___ as an option)
- especially when ___ to oral or topical 5-ASAs (can add to 5-ASA)
- limit budesonide use to < __ - __ weeks

PO corticosteroids ( ___ 40-60 mg/day) may be used for patients refractory to ASAs
* topical corticosteroids (foams, enemas, suppository) are effective for distal disease (ie, ___ , or ___ )

Answer 5

• budesonide, prednisone
• nonresponsive
• 8-16
• prednisone
• left sided, proctitis

Question 6

Mild-Mod. Active UC

T or F: oral and topical mesalamine should not be used together

Answer 6

FALSE: Remember: combo
oral and topical mesalamine can be more effective

Question 7

Moderate-Severe Active UC

• 4-6 stools per day, +/- blood in stool, some systemic symptoms
• 5-ASA therapy possible for moderate, but not ___ disease
• systemic corticosteroids (PO prednisone 40-60 mg/day)
• for moderate can use oral ___

consider ___ inhibitors/biologics (potentially newer small molecules) in pts unresponsive to ASAs/other therapy, pts who are steroid dependent, pts who fail steroids

Answer 7

• severe
• budesonide
• TNF-a

Question 8

Moderate-Severe Active UC

TNF inhibitor (3)

anti-integrin (1)

IL12/IL-23 inhibitors (3)

JAK inhibitor (2)
- black box warning, only if failed TNF inhibitor

SP1 inhibitor (2)

Answer 8

• infliximab, adalimumab, golimumab
• vedolizumab
• ustekinumab, mirikizumab, risankizuab
• upadacitinib, tofacitinib
• ozanimod, etrasimod

Question 9

Moderate-Severe Active UC

AGA suggests against using ___ for induction or maintenance

___ monotherapy is option

thiopurine monotherapy should not be used for ___
- thiopurine monotherapy is option for ___
- AGA makes no recommendation regarding biologics monotherapy vs thiopurine monotherapy for maintenance

Answer 9

• methotrexate
• biologic
• induction
• maintenance

Question 10

Moderate-Severe Active UC

AGA recommends combining TNF-antagonists, vedolizumab, or ustekinumab with ___ or ___ rather than monotherapy
- patients with less severe disease, or those who place relative value on minimizing ADRs vs maximizing efficacy may choose biologic monotherapy

AGA suggests ___ use of biologics (with/without immunomodulators) rather than gradual step-up (very low quality evidence)
- especially in moderate-severe disease at high risk of colectomy
- those with less severe disease who place a higher value on the safety of 5-ASA agents may prefer gradual step up

Answer 10

• thiopurines, MTX
• early

Question 11

Moderate-Severe Active UC

in patients who have achieved remission with biologic agents and/or immunosuppressives or tofacitinib, AGA recommends ___ continuing
5-ASA for induction or maintenance

Answer 11

AGAINST

Question 12

Mod. -Severe Active UC

T or F: certolizumab is approved for UC

Answer 12

FALSE
IMPORTANT: certolizumab is NOT approved for UC; golimumab IS approved for UC

Question 13

Severe-Fulminant UC

require inpatient tx
- consider ___ (bowel rest)

parenteral corticosteroids
- methylprednisolone (16-20 mg q 6 h, AGA recommends 40-60 mg/day)
- hydrocortisone (100 mg q 8 h)
- generally treat __ - __ days (then transition to PO)

consider TNF-α inhibitors ( ___ ) or ___ in pts unresponsive to IV steroids
- cyclosporine: start IV, transition to PO, with transition to ___ or ___
- effective, but may delay rather than prevent colectomy

___ has similar efficacy to ___

Answer 13

• NPO
• 3-7
• infliximab, cyclosporine
• 6-P, AZA
• infliximab, cyclosporine

Question 14

UC: Maintenance of Remission

generally use an ___ , a TNF-α antagonist
( ___ and ___ ), ___ , or ___
- choice depends on part in the tx required to induce remission
- no role for ___ ; ___ not studied

ASAs
- newer ___ derivatives better tolerated than ___ (2-3 g/day mesalamine equiv)
- use mesalamine ____ (if left-sided disease) or ___ (if proctitis)
- may use ___ of topical/systemic (more effective than either alone)

in pts who are steroid dependent or unresponsive to ASAs
- ___ or 6- ___ (slow to work: 3-6 months)

TNF-α antagonist for pts who required a TNF-α antagonist for induction (or who fail ___ )
* possibly with AZA
* ___ , ___ , or ___

Answer 14

• ASA, infliximab, adalimumab, AZA, 6-MP
• corticosteroids, budesonide
• mesalamin, sulfasalazine
• enemas, suppositories
• combo
• AZA, 6-MP
• AZA
• infliximab, adalimumab, golimumab

Question 15

UC: Maintenance of Remission

anti-integrin (1)

IL12/IL-23 inhibitors (3)

JAK inhibitor (2)
* black box warning, only if failed TNF inhibitor

SP1 inhibitor (2)

Answer 15

• vedolizumab
• ustekinumab, mirikizumab, risankizumab
• upadacitinib, tofacitinib
• ozanimod, etrasimod

Question 16

Mild-Moderate Active CD

___ marginally effective for treating symptoms of mild/mod colonic CD
- not isolated small bowel CD
- does not result in mucosal ___

mesalamine derivatives have ___ efficacy, no longer recommended, should not be used
- despite this, mesalamine derivatives frequently tried since well tolerated/familiar
- consider formulation and site of action

Answer 16

• sulfasalazine
• healing
• minimal

Question 17

Mild-Moderate Active CD

controlled release ___
- option for pts with ilealeocecal ( ___ ) or ___ sided disease

antibiotics
- e.g. metronidazole +/- ciprofloxacin
- variable efficacy, possible option if perianal disease, fistulizing disease, unresponsive to sulfasalazine
- not recommended as primary therapy

Answer 17

• budesonide
• distal, right

Question 18

Mild-Moderate Active CD

T or F: mesalamine has no efficacy in CD

Answer 18

True
- sulfasalazine has marginal efficacy

Question 19

Moderate-Severe Active CD

failed treatment for mild/mod disease, systemic symptoms (fever, wt. loss, abd. pain/tenderness, anemia, vomiting, diarrhea, etc)
- systemic corticosteroids ( __ prednisone 40-60 mg/day)
- tx until resolution of sx and resumption of ___
- may be more effective than ___

hospitalized patients may receive ___ corticosteroids
- methylprednisolone (16-20 mg q 6 h) or hydrocortisone (100 mg q 8 h)

early ___ therapy (with/without immunomodulators) may be beneficial

Answer 19

• PO
• weight gain
• budesonide
• IV
• biologic

Question 20

Moderate-Severe Active CD

TNF-α antagonists effective
- can use in patients failing ___ tx, ___ dependent pts
- ___ + AZA (or possibly MTX) may be more effective than either alone

___ may be used
* SC administration
* possible option in pts who lose response to infliximab

AGA suggests ___ or ___ plus thiopurine for induction and maintenance over monotherapy in those naïve to biologics and immunomodulators

___ may be used (AGA recommends other agents over certolizumab based on results of meta analysis)

Answer 20

• immunosuppressive, steroid
• infliximab
• adalimumab
• infliximab, adalimumab
• certolizumab

Question 21

Moderate-Severe Active CD

Agents targeting leukocyte trafficking
- ___ - with or without immunomodulator
- ___ - not preferred, only use for maintenance if JC negative

IL-12/IL-12 and IL-23 antagonists
- ___ and ___

JAK inhibitor
- ___ : if failed TNF inhibitor

Answer 21

• vedolizumab
• natalizumab
• ustekinumab, risankizumab
• upadacitinib

Question 22

Moderate-Severe Active CD

immunomodulator (AZA and 6-MP) ___ not recommended to induce remission (may help
maintain remission after induced w ___ , may be
steroid sparing)
- may use monotherapy in maintenance of remission

___ (up to 25 mcg weekly IM or SC) may be used
to induction (esp in steroid-dependent CD) and for
maintaining remission
* ___ should NOT be used for CD
* ___ or ___ should not be used

Answer 22

• monotherapy, steroid
• MTX
• cyclosporine
• 5-ASA, sulfasalazine

Question 23

Severe-Fulminant CD

persistent sx/systemic toxicity despite corticosteroid
or biologic tx, cachexia, rebound tenderness,
obstruction, or abscess; CDAI > 450
* require inpatient tx
* consider ___ (bowel rest)
* supportive care

___ corticosteroids (if no abscess)
- methylprednisolone (16-20 mg q 6 h) or hydrocortisone
(100 mg q 8 h)
- generally treat 3-7 days (then transition to PO)

may consider ___ (or other biologic) if not
attempted prior
- may be preferred if fulminant

Answer 23

• NPO
• parenteral
• infliximab

Question 24

CD: Maintenance of Remission

minimal evidence ___ and PO ___ derivatives are effective
- may try due to favorable adverse effect profile
- not recommended in moderate-severe CD

no role for systemic ___
- ___ has minimal long-term efficacy à not recommended for >4 months

Answer 24

• sulfasalazine, mesalamine
• corticosteroids
• budesonide

Question 25

# CD: Maintenance of Remission ___ and ___ are effective - esp. in steroid-induced or infliximab-induced remission MTX - alternative to AZA and 6-MP, esp. in pts w initial response to MTX - SQ only (PO not recommended)

Answer 25

AZA, 6-MP

Question 26

# CD: Maintenance of Remission ___ antagonists are options for CD maintenance - ADA suggests use of infliximab or adalimumab in combination with ___ or ___ in patients who are naïve to biologics and immunomodulators - certolizumab - ant-integrin: ___ - Il-12/IL-23 antagonists: ___ , ___ - ___ not recommended clinical controversy: bottom-up or top-down approach * in moderate-severe disease, AGA suggest early introduction with a biologic +/- and immunomodulator vs delaying their use while trying 5-ASAs and/or corticosteroids

Answer 26

- TNF-a - infliximab, adalimumab - vedolizumab - ustekinumab, risankizumab - natalizumab

Question 27

# Follow-up: Monitor and Evaluate - resolution of active disease symptoms (24-48 hours for ___ patients, 7-14 days for ___ ) - evaluate symptoms, labs for efficacy and toxicity - monitor for ADRs - TDM - assess adherence - determine need for dose adjustment (e.g. corticosteroids)

Answer 27

- hospitalized, outpatients