chronic inflammatory bowel diseases
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Chronic inflammatory Bowel Diseases. By Prof. Abdulqader Alhaider 1434H. Chronic inflammatory bowel diseases (IBD) IBD is a group of auto-immune disorders in which the intestines become inflamed. are chronic inflammatory bowel disease which have relapsing and limiting course. - PowerPoint PPT PresentationTRANSCRIPT
Chronic inflammatory Bowel DiseasesBy
Prof. Abdulqader Alhaider1434H
Chronic inflammatory bowel diseases(IBD)
IBD is a group of auto-immune disorders in which the intestines become inflamed.
are chronic inflammatory bowel disease which have relapsing and limiting course.
The major types of IBD are Crohn's disease and ulcerative colitis (UC).
Differences between Crohn's disease and UC
Ulcerative colitis
Crohn's disease
Restricted to colon & rectum
affect any part of the GIT, from mouth to anus
Location
Continuous area of inflammation
Patchy areas of inflammation (Skip
lesions)
Distribution
Shallow, mucosal May be transmural, deep into tissues
Depth of inflammation
Toxic megacolon Strictures, ObstructionAbscess, Fistula
Complications
Ulcerative colitis Crohn’s disease
Limited to colonic mucosa and may reach proximal part of the colon.Bloody diarrhea
Effect the entire thickness of the wall and involve any part of GIT. No blood
Symptoms of UC:
-Abdominal pain; Diarrhea and bleeding. Complications: Anemia ; megacolon,
fever, abdominal pain, dehydration, colon cancer.
Treatment of IBD
1. 5-amino salicylic acid compounds (5-ASA).
2. Glucocorticoids3. Immunomodulators 4. Biological therapy (TNF-α inhibitors).5. Surgery in severe condition
Drugs Used for Rx and maintenance of I.B.DI) Anti-inflammatory Drugs
1) A. 5-Aminosalicylic Acid:MOA: inhibit prostaglandins and leukotriens synthesis; decreases neutrophil chemotaxis and decreases free radicles production. scavenging free radical productionNote: since it is irritant to GIT, this drug should not be given orally as such.
Formulations: a)Sulpha containing 5-Aminosalicylic Acid
(e.g: Sulphasalazine)Sulphasalazine is a Prodrug )20-30 %( absorbed by intestine, secreted in the
bile and hydrolysed in ileum and colon by isoreductase .
Sulfapyridine + 5- ASA Hydrolysed in bacteria in ileum
Linked by Azo group and colon
Which part is active and is it absorbed?
Sulphasalazine (Continue…)Prodrug used in maintenance therapy less
effective in acute attack ;Use for U.colitis; Crohn’s colitis but not
Crohn’s of small intestine Why .?
Note: Nowadays it is seldom to be used for Crohn’s disease )new 5-ASA are preferred
but still use for UC(.
- Side Effects : - Muscular pain 29% , N/V,
Diarrhea - Crystalluria and interstitial nephritis
Hypersensitivity reactions as: skin rash, fever, aplastic anemia. Why?
Inhibit absorption of folic acid `)megaloplastic anemia(
Infertility in man )decrease sperm counts(. However, it is save in pregnancy.
B. Non-sulpha containing 5-Aminosalicylic Acid
1. Mesalamines Compounds Formulations that have been designed to deliver
5-ASA in small & large colon. e.g. pentasa (orally): time release microgranules
that release 5-ASA through the small intestinee.g. Asacol 5-ASA coated in pH sensitive resin that
dissolved at pH 7 e.g. Rowasa (enema) or Canasa (suppositories) Treat and maintain remission in mild to moderate
ulcerative colitis. Well tolerated, less side effects (sulfa free).
2. Azo compoundsCompounds contain 5-ASA and connected by azo bond to another molecule of 5-ASA or to inert compound
Azo structure (N=N)reduces absorption in small intestineBacteria cleave the azo dye and release 5-ASA in
terminal ileum and colon
Examples:Olsalazine )Two molecules )dimer( of 5-ASA linked together by diazo bond which pass small intestine to
ilium and colon( (Balsalazide 5-ASA + inert carrier (Colazal).
Stomach
Small Intestine
Large Intestine
Azo Compounds
Mesalamine in microgranules
Mesalaminew/ eudragit-S
Oral 5-ASA Release Sites
Block PGs, LTs & cytokine production / NF-kB activation Inhibit bacterial peptide–induced neutrophil chemotaxis &
adenosine-induced secretion, Scavenge reactive oxygen metabolites
Mechanism of action
AMINOSALICYLATES [5-ASA]
Clinical uses of 5-amino salicylic acid compounds
Induction and maintenance of remission in mild to moderate ulcerative colitis & Crohn’s disease
(First line of treatment). Are NOT USEFUL in actual attack or severe forms of
IBD. Rheumatoid arthritis (Sulfasalazine only) Rectal formulations are used in ulcerative proctitis and
proctosigmoiditis.
2. CorticosteroidMOA:
Inhibits phospholipase A2, inhibit gene expression of NO synthase, COX-2
Inhibit inflammatory cytokines (TNF-a)
Indications:
Treat moderate – severe ulcerative colitis
)prednisone P.O. 40-60 mg/day for 2 weeks
Less effective as prophylactic (maintaining remission).
Budesonide as controlled release oral (9 mg/day) formulation (Entocort).
Hydrocortisone enema or suppository for rectum or sigmiod colon
used also for extracolonic manifestations such as ocular lesion, skin disease and peripheral arthritis
;
II. Immunomodulators Are used to induce remission in IBD in activeor severe conditions or steroid dependent orsteroid resistant patients.
Immunomodulators include: Methotrexate Purine analogs:(azathioprine & 6-mercaptopurine).
II( Immunomosuppressive Agents :
1( Azathioprine; is pro-drug of 6-mercaptopurine that Inhibit purine synthesis
M.O.A.: Suppress the body’s immune systemClinical indications: for Rx and maintenance of remission of severe conditions and steroids dependent or resistant )ulcerative and Cronn’s disease(Side Effects:- N/V and bone marrow depression; LFT changes- Hypersensitivity reactions Why?
2. Methotrexate:MOA: dihydrofolate reductase inhibitor works as antimetabolite. Uses: Cronn’s disease )to induce and
maintain remission(; Rheumatoid Arthratis and cancer.
Side effects:Bone marrow suppresion.
Monoclonal antibodies used in IBD(TNF-α inhibitors)
InfliximabAdalimumab Certolizumab
Infliximab Is a monoclonal IgG antibodies. 25% murine – 75% human. Anti-TNF-α: Inhibits soluble or membrane –bound TNF-α
located on activated T lymphocytes and Given as infusion (5-10 mg/kg). has long half life (8-10 days) 2 weeks to give clinical response
Uses Severe crohn’s disease. Patients not responding to Immunomodulators or glucocorticoids. Treatment of rheumatoid arthritis Psoriasis
Side effects Acute or early adverse infusion reactions
(Allergic reactions or anaphylaxis in 10% of patients).
Delayed infusion reaction (serum sickness-like reaction, in 5% of patients).
Pretreatment with diphenhydramine, acetaminophen, corticosteroids is recommended.
Side effects (Cont.) Infection complication (Latent tuberculosis,
sepsis, hepatitis B).
Loss of response to infliximab over time due to the development of antibodies to infliximab
Severe hepatic failure. Rare risk of lymphoma.
Adalimumab (HUMIRA) Fully humanized IgG antibody to TNF-αAdalimumab is TNFα inhibitorIt binds to TNFα, preventing it from activating TNF
receptors Has an advantage that it is given by subcutaneous
injection is approved for treatment of, moderate to severe
Crohn’s disease, rheumatoid arthritis, psoriasis.
Certolizumab pegol (Cimzia)
Fab fragment of a humanized antibody directed against TNF-α
Certolizumab is attached to polyethylene glycol to increase its half-life in circulation.
Given subcutaneously for the treatment of Crohn's disease & rheumatoid arthritis
Summary for drugs used in IBD5-aminosalicylic acid compounds
Azo compounds:sulfasalazine, olsalazine, balsalazide
Mesalamines: Pentasa, Asacol, Rowasa, Canasa Glucocorticoids prednisone, prednisolone, hydrocortisone, budesonideImmunomodulators
MethotrexatePurine analogues: Azathioprine&6mercaptopurine
TNF-alpha inhibitors (monoclonal antibodies)Infliximab – Adalimumab - Cetrolizumab
Inductive TherapiesFor UCAminosalicylatesCorticosteroidsCyclosporin >
For CDAminosalicylatesCorticosteroidsAntibioticsInfliximab >
ImmunosupressorsAzathioprine6-MPMethotrexateAminosalicylatesInfliximab NO corticosteroids
Maintenance Therapies
Severe
Moderate
Mild
Systemic Corticosteroids
Aminosalicylates
Surgery
Oral SteroidsAZA/6-MP
CyclosporineInfliximab