Moderate Severe Acute Crohns Colitis

Moderate-severe Crohn's colitis includes a spectrum of patients that have not responded to treatment for mildmoderate disease or individuals who are acutely ill with fever, dehydration, malnutrition, anemia, diarrhea, abdominal tenderness, or an inflammatory mass. Patients

MILD-MODERATE DISEASE

SEVERE DISEASE

Espinha Peixe Ferramenta
FIGURE 80-1. Treatment algorithm for induction and maintenance medical therapy for Crohn's colitis. ASA = aminosalicylic acid; IV = intravenous; 6-MP = 6-mercaptopurine.

with an incomplete response to corticosteroids are candidates for infliximab therapy, usually given as an outpatient, whereas those presenting with severe-fulminant symptoms or evidence of an abscess or peritioneal signs require hospitalization.

Infliximab

Anti-TNF therapy with the chimeric monoclonal antibody, infliximab, has been embraced as an inductive and maintenance therapy for patients with active luminal CD not responding to the above therapies (steroid-refractory or dependent) or for patients with fistulizing disease. Enthusiasm for its' efficacy must be tempered by knowledge of the potentially serious side effects, limitations in availability due to its high cost, and need for long-term therapy. The clinical response is rapid and usually noted within the first days or weeks after infusion. Up to 80% of patients with active CD will respond and over 50% of patients with fistula have complete cessation of drainage after a series of infusions at 0,2, and 6 weeks with 5 mg/kg doses.

Infliximab should be administered initially, at a dose of 5 mg/kg with the 3-dose induction regimen to reduce immunogenicity, and the majority of patients who respond will require continued maintenance therapy at an average interval of every 8 weeks. There is growing recognition and acceptance that concurrent administration with an immunomodulator and/or corticosteroids improves the long term outcome of therapy by reducing antibody-to-infliximab formation. Potential side effects include immunogenicity to infliximab, development of autoanti-bodies, and the risk of opportunistic infections.*

Up to 3% of patients develop an acute, anaphylactoid, infusion reaction that can usually be managed conservatively by temporarily stopping the infusion, treatment with diphen-hydramine, and restarting the infusion at a slower rate. The acute infusion reactions have been associated with anti-infliximab antibodies and are also associated with decreased duration of response to infliximab. The acute infusion reactions are in contrast to delayed hypersensitivity reactions that occur in up to 19% of patients, many of whom who have had a significant delay of many months to years between infusions. This serum sickness-like reaction is thought to be due to the development of high-titer, anti-infliximab antibodies. The incidence of antibodies to infliximab is reduced by concomitant corticosteroids, azathioprine (AZA) or 6-mercaptopurine (6-MP) administration, and continuous rather than episodic administration.

Infliximab and other anti-TNF agents have also been associated with increasing titers of antinuclear and anti-double stranded DNA (dsDNA) antibodies that, rarely, can be associated with a drug-induced lupus syndrome that resolves with discontinuation of anti-TNF therapy. Immunosuppression

*Editors Note: Some physicians utilize azathioprine or methotrexate therapy before starting infliximab.

and opportunistic infection can occur, particularly intracellular infections such as Mycobacterium tuberculosis, histo-plasmosis, cryptococcidiosis, and listeriosis, related to anti-TNF therapy such that skin testing and chest radiographs are recommended prior to initiating therapy with infliximab or other anti-TNF agents.

Cyclosporine

Cyclosporine, used successfully in severe UC, can also be used in colonic CD. Continous intravenous infusion at doses of 2 to 4 mg/kg/d may avoid colectomy, although oral dosing has not proved effective for either induction or maintenance of remission. Immunosuppression and nephrotoxicity are the primary side effects. Renal function and serum drug levels must be monitored regularly. Other significant side effects are hypertension, seizures (especially in hypocholesterolemic patients) (< 120 mg/dL), and opportunistic infection.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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