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IBD

  • Crohn outpt tx

    • mesalamine up to 4 g/day or sulfsalazine (more side effects) 3-5 g/day
    • prednisone 40-60 mg/day
    • immunosuppressive drugs
      • for steroid-sparing, healing fistula or serious surgical contraindications
      • 6-mercaptopurine 1 to 1.5 mg/kg/day or azathioprine 2-2.5 mg/kg/day
    • antibiotics
      • ciprofloxacin 500 mg q 8-12 hours
      • metronidazole 500 mg q 6 hours
      • rifaximin 800 mg bid
    • infliximab 5 mg/kg IV if refractory
    • tx diarrhea
      • loperamide 4-16 mg/day
      • or diphenoxylate 5-20 mg/day
      • or cholestyramine 4 g 1-6 times daily
    • Surgery if fail medical therapy
  • UC outpt tx

    • topical steroid (beclomethasone, hydrocortisone)
    • if fail topical therapy: mesalamine PO up to 4 g/day
    • next line: prednisone 40-60 mg/day PO until remission, then taper
    • if refractory: 6-mercaptopurine 1-1.5 mg/kg/day or azathioprine 2 mg/kg/day
    • surgery if fail medical therapy
  • IBD Admission orders

    • Admit: Floor
    • Diagnosis: IBD
    • Condition: Guarded
    • Vital Signs: q 8 hours, check orthostatic BP q AM
    • Allergies:
    • Nursing: I/O, please record all stools, daily weights
    • Diet: NPO
    • Activity: As Tolerated
    • Labs:
      • CBC with differential
      • Chem, LFTs
      • prealbumin, vitamin C, zinc level
      • abdominal films
      • CXR
      • Stool culture, and C. difficile test
    • IV: D5NS at 250 mL/h x 2 Liters, then Call MD to Reassess
    • Special: GI consult, surgical consult (peritonitis, abscess, refractory to tx)
    • Medications:
      • Prednisone 30 mg IV q 12 hours
      • consider cyclosporin, infliximab per GI consult
      • Metoclopramide 10 mg IV q 6 hours prn nausea
      • Hyoscyamine 0.125 mg sublingually q 6 hours prn abdominal cramping
      • Hydromorphone (Dilaudid) 1-2 mg IV q 4 hours prn severe pain
      • Heparin 5000 units SQ q 8 hours
      • Ciprofloxacin and metronidazole IV if abscess
  • Discharge

    • criteria: afebrile, tolerating PO
    • meds: consider azathioprine, MTX, mesalamine, infliximab
    • education:
      • steroids; osteoporosis; Take Ca, Vit D
      • AZA and 6-MP; marrow toxicity; weekly CBC 1st month, genetic testing for TPMT mutation
      • infliximab; reactivation TB; TST/PPD
    • f/u with GI

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