SOAP note: Ulcerative colitis (UC)

Patient Profile Sex: Female Age: 40 yrs Weight: 59.9 kg Height: 150 cm BMI: 26.62 kg/m2 BSA: 1.58 m2

Date: 6 May 2010

CC: ทองเสีย PI: 3days PTA ผูปวยถายอุจจาระมีเลือดปน

พบ Lower GI bleeding

Dx: Ulcerative colitis (UC)

Rx: Miracid® (Omeprazole 20 mg)

1 x 2 ac

Salofalk® (Mesalazine 500 mg)

1 x 3 pc

ผูปวยถูก Refer จาก รพ.กรุงเทพฯ ใหเขารับการรักษาที ่รพ.มิชชั่น ระหวาง Refer ผูปวยขาดยา 1 สัปดาห

Rx จาก รพ.กรุงเทพฯ： Salazopyrin®

(Sulfasalazine 500 mg) 3 x 2 pc

PMH: 17/09/51 ผูปวยถายเปนเลือด → Admit colonoscopy

R/O: UC

1 วันตอมา มาดวยอาการถายอุจจาระเปนเลือดสด

ทํา Colonoscopy

Dx: Colitis with hemorrhoids

Rx: Ofloxacin 200 mg 1 x 2 pc

Transamin® (Tranexamic acid 250 mg)

1 x 3 pc

Salazopyrin® 1 x 3 pc

1 สัปดาหตอมา GI bleeding

Biopsy: Hemorrhoids stage II

Dx: Colitis with hemorrhoids

Rx: Sulfasalazine 1 x 3 pc

Miracid® 1 x 2 ac

Magesto-F® 1 x 3 pc

Prednisolone 2 x 1 pc

Fibrogel 1 ซอง hs

1 สัปดาหตอมา ถายเปนเลือด

Gastroscopy Dx: Gastritis

2 สัปดาหตอมา ถายเปนเลือดเล็กนอย

Rx: Proctosedyl® 1 x 1 hs

Salazopyrin® 1 x 3 pc

Miracid® 1 x 2 ac

Magesto-F® 1 x 3 pc

Fibrogel® 1 ซอง hs

PE: V/S: - HEENT： -

Heart: - Lung: -

Abd： Lower GI Bleeding

Ext: - Neuro: -

Impression: Ulcerative colitis (UC)

R/O: Ulcerative colitis

Acute gasteroenteritis (AGE)

FH/SH: No data

LAB: -

ALL: No known drug and food allergies

บันทึกการสั่งใชยา Ofloxacin 200 mg

1 x 2 pc ใชฆาเช้ือท่ีอาจเปนสาเหตุของ UC

Colofac®

(Meberverine HCl 135 mg)- 1 x 3 ac- บรรเทาอาการทองเสีย

Salazopyrin®

(Sulfazalazine 500 mg)- 3 x 2 pc- รักษาและควบคุมอาการเนื่องจากการอักเสบ

SOAP note Problem list: UC Subjective data: ทองเสีย Objective data:

Colonoscopy & Biopsy: Dx: Colitis with hemorrhoids เมื่อ 1 ป 9 เดือนที่ผานมา

Abd: Lower GI bleeding

Assessment

Ulcerative colitis (UC) Caused by inflammation

Lower GI tract: Colon & Rectum Mucosal ulceration: Mucosa & Submucosa Continuous inflammatory pain

Signs and Symptoms Diarrhea Abdominal cramp Blood in the stool Weight loss Blurred vision Eye pain

Photophobia Arthritis Raised, red, tender

nodules Fever Tachycardia

Ulcerative colitis (UC)

PE Hemorrhoids Anal fissures Perirectal abscesses Ocular complications:

Irisitis, Uveritis, Episclerisitis

Dermal manifestations: Erythema nodosum, Pyoderma gangreosum, Aphthous ulceration

Ulcerative colitis (UC) Lab

↓ Hct/Hgb ↑ ESR Leukocytosis Hypoalbuminemia

UC: severity

> 6 bloody stools per day Systemic disturbance: Fever (Body °T > 37.5 °C), Tachycardia (HR ≥ 80 bpm) Anemia ESR > 30

> 4 stools per day Minimal systemic disturbance

Fewer than 4 stools daily with or w/o blood No systemic disturbance A normal ESR

SevereModerateMild

UC: Factors Infection

Bacteria E.coli C.difficle H.pyroli C.trachomatis

Viruses Helminths

Drug NSAIDs: impairment of

mucosal barrier at GIT

Immune defects Autoimmune: 70% in UC

patients Imbalance between pro-

and anti-inflammatory cytokines

Psychological factors Stress ↔ Relapse

Genetics: HLADR2 gene

UC: Complications Severe inflammation Toxic megacolon Perforation Extraintestinal disorders Higher risks for cancer at GI tract

UC: Treatments

Corticosteroids：Rapid anti-inflammatory agents Prednisolone Dexamethasone

Step 2 Moderate to Severe

Immune modifiers: steroid-sparing action

Azathioprine, 6-Mercaptopurine TNF-inhibitors: Infliximab, Adalimumab, Certolizumabpegol, Etanercept Tacrolimus Methotrexate Anti-integrin antibody: Natalizumab

Aminosalicylates:Anti-inflammatory agents

Sulfasalazine(Salazopyrin®) Mesalazine(Salofalk®)

Antibiotics Ciprofloxacin Metronidazole

Step 3 Refractory

Step 1Mild

UC: Supportive treaments Anti-diarrheal agents

Mu agonists: Loperamide, Diphenoxylate Cholestyramine

Anti-spasmodics Anti-cholinergics: Dicyclomine Hyoscine-N-butylbromide

Acid-suppressant agents Histamine-2-antagonists Proton pump inhibitors

Assessment ผูปวยขาดยารักษาเปนเวลา 1 สัปดาห

การรักษาขาดความตอเน่ือง → การดําเนินของโรคไมดีข้ึน Blood in stool & Diarrhea

Indication: Treatment of Irritable bowel syndrome (IBS) Diarrhea-predominant type

A muscarinic M3 receptor antagonist. M3 receptors: smooth muscle cell at GI tract ↓ Contractile activity + ↓ Small bowel motor activity

↓ GI motility + ↓ Abdominal cramp Specific at GI tract: no Anti-cholinergic S/E

√： supportive treatment for diarrhea.

Colofac® : Mebeverine HCl

Salazopyrin®: Sulfasalazine Sulfasalazine

Sulfapyridine + 5-Aminosalicylic acid Indication: Treatment mild – moderate UC Initial dosage: 3 – 4 g/day

1-2 g/day in case GI intolerance Dosage interval: not exceeding 8 hr Administration: tid-qid, after meals recommended. 3 x 2 pc: dosage interval ≈ 12 hr;

High dosage per meal ↑GI S/E

√√Metronidazole

√√Ofloxacin√√Ciprofloxacin

C.trachomatisH.pyroliC.difficleE.coli

Ofloxacin could be substituted for Ciprofloxacin for the treatment of UC.

Possible to use in combination with Metronidazole.

4.6-6.21.6Cmax (µg/mL)

≈ 9≈ 4Half –life (hr)

20-40%32%Protein binding

98%70 – 80%Bioavailability

OfloxacinCiprofloxacin

Plan Goal

To improve signs & symptoms : Normal stool

To maintain remission. To prevent complications of

UC. Improvement in QOL: affecting

daily life at least as possible． A decrease rate in

hospitailization.

Therapeutic plan Salazopyrin® :

2 tab tid pc ↓ GI intolerance

Continue Colofac®:1 tab tid ac

Continue Ofloxacin:1 tab bid pc

Plan Monitoring efficacy

End point:Relief from diarrhea,

improved signs and symptoms of UC, maintenance of remission

Frequency of watery stools < 3 times/day

Normal stool, no bloodFrequency: once a week.

Monitoring safety Ofloxacin

N/V, headache, hypersensitivity

Sulfasalazine GI intolerance, Hemolytic

anemia, Leukopenia, Neutropenia (Monitor CBC druring drug use)

Mebeverine Headache

Plan Future plan

Test CBC: WBC, Hct, Hgb,

MCV Stool swab Occult blood test

F/U: assessment of signs and symptoms in 1 week.

No symptoms improved or getting worse: Consider to add

metronidazole Consider to add low dose

CS or use high doses of sulfasalazine．

Plan Patient education

Explanation about the disease. Lifestyle modification How to use drugs, precautions & storage. S/E & ADRs Avoid to use NSAIDs

Thank you for your attention