A 38-year-old man is evaluated in follow-up after a analysis of ulcerative colitis. Ten days in the past he was began on prednisone, 60 mg/d, however his signs haven’t improved. He has six to 9 bloody bowel actions per day and average stomach ache. He has decreased his oral consumption as a result of consuming exacerbates his ache and diarrhea.
On bodily examination, temperature is 37.zero °C (98.6 °F), blood stress is 110/56 mm Hg, and pulse charge is 96/min. He’s pale however in no misery. The stomach is diffusely tender with out distention, guarding, or rebound.
Laboratory research reveal a hemoglobin stage of 9.7 g/dL (97 g/L) and a leukocyte depend of 6300/µL (6.three × 109/L).
Stool tradition and Clostridium difficile assay are unfavourable.
Which of the next is probably the most acceptable therapy?
A. Enhance prednisone to 80 mg/d
B. Provoke adalimumab
C. Provoke ciprofloxacin and metronidazole
D. Provoke mesalamine
E. Provoke sulfasalazine
MKSAP Reply and Critique
The proper reply is B. Provoke adalimumab.
Essentially the most acceptable therapy is to provoke an anti–tumor necrosis issue (anti-TNF) agent corresponding to adalimumab. This affected person has average to extreme ulcerative colitis that’s not responding to 60 mg/d of prednisone. Average to extreme ulcerative colitis is commonly handled with oral glucocorticoids corresponding to prednisone, 40 to 60 mg/d. Sufferers whose illness doesn’t reply to oral glucocorticoids needs to be hospitalized and given intravenous glucocorticoids or needs to be handled with an anti-TNF agent. Randomized managed scientific trials have proven three anti-TNF antibodies (infliximab, adalimumab, and golimumab) to be efficient for inducing and sustaining remission in sufferers corresponding to this with ulcerative colitis. Indications for hospital admission embrace dehydration, incapacity to tolerate oral consumption, fever, vital stomach tenderness, and stomach distention.
A meta-analysis of scientific trials confirmed that utilizing doses of prednisone above 60 mg/d supplies little if any extra efficacy and produces extra unwanted effects.
Ciprofloxacin and metronidazole needs to be utilized in sufferers with extreme colitis related to excessive fever, vital leukocytosis, peritoneal indicators, or poisonous megacolon. Nevertheless, antibiotics will not be indicated in a affected person corresponding to this with colitis with out indicators of systemic toxicity.
Sufferers with gentle to average ulcerative colitis reply effectively to 5-aminosalicylate brokers. Sufferers with proctitis or left-sided colitis ought to obtain topical remedy with a 5-aminosalicylate or hydrocortisone suppositories or enemas. If sufferers require repeated programs of glucocorticoids or turn out to be glucocorticoid dependent, thiopurines (6-mercaptopurine or azathioprine) or an anti-TNF agent needs to be initiated (methotrexate has not been proven to be efficient in ulcerative colitis). Anti-TNF brokers needs to be utilized in sufferers who don’t preserve remission with thiopurines or sufferers whose illness is refractory to glucocorticoids. It’s unlikely that 5-aminosalicylates can be helpful on this affected person with extra extreme illness that’s refractory to prednisone.
- Sufferers with average to extreme ulcerative colitis whose illness doesn’t reply to oral glucocorticoids needs to be handled with both intravenous glucocorticoids or an anti–tumor necrosis issue agent.
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