Patient Care and Monitoring

1. Evaluate the patient's symptoms to determine if they are consistent with UC or CD. Determine whether the patient has evidence of extraintestinal manifestations or Gl complications related to IBD. Identify any psychosocial problems related to the presence of IBD.

2. If the patient is presenting with an exacerbation of preexisting IBD, determine if the symptoms are similar in type and severity to the patient's previous episodes.

3. Assess the patient's medical history for pertinent drug allergies, tobacco use, and current prescription and nonprescription drug therapies. Determine if any of the medications could exacerbate IBD. If applicable, inquire about adherence or recent changes to the patient's current IBD drug regimen.

4. Use available diagnostic laboratory, endoscopic, and imaging data to gauge the extent and severity of the patient's disease.

5. Construct a drug treatment plan based on the disease severity and location. Identify potential contraindications or financial barriers to drug therapy. Inquire if the patient has an aversion to or inability to properly use certain drug formulations that you may wish to recommend, such as topical (rectal) products.

6. Assess whether the patient will require maintenance therapy after remission induction. If so, identify the treatment duration. Decide when the patient should receive follow-up care.

7. Outline parameters to evaluate the efficacy and toxicity of the drug regimen you are recommending. Determine whether the patient will need preventive drug therapy or diagnostic testing to prevent or screen for potential drug-related toxicities.

8. Educate the patient on proper use of drug therapy, including when to expect symptom improvement after initiation oftreatment and which signs or symptoms to report that might be related to adverse drug effects.

9. Provide patient education on the proper use ofaminosalicylate medications and assess regularly for adherence. Include the following:

• Proper use of suppositories and enemas

• The appropriate number of tablets or capsules to take per day. Reinforce that tablets and capsules are delayed-release and should not be crushed, opened, or chewed.

• Appropriate dose titration, particularly with oral sulfasalazine

• The time frame the patient can expect improvement based on drug dose and disease severity

• Signs or symptoms of potential adverse effects

10. Once remission is achieved, evaluate the patient's drug regimen to determine if dose reductions or changes in frequency ofadministration are required. Reinforce the need for adherence to drug therapy in order to maximize effectiveness.

11. Educate patients about their disease state. Refer patients to available support groups or IBD organizational resources if they are having difficulty in coping with their disease.

• Prior to initiating methotrexate therapy, obtain complete blood count, serum creatinine, liver function tests, chest x-ray, and pregnancy test (if female). Monitor blood counts weekly for 1 month, then monthly thereafter.

• Prior to initiating infliximab, adalimumab, or certolizumab obtain a tuberculin skin test to rule out latent tuberculosis. Also monitor patients with a prior history of hepatitis B virus infection for signs of liver disease, such as jaundice. Assure that patients do not have a clinically significant systemic infection or New York Heart Association Class III or IV heart failure.

• In patients receiving infliximab, monitor for infusion-related reactions such as hypotension, dyspnea, fever, chills, or chest pain when administering IV doses.

• In patients with fistulae, monitor at every infliximab, adalimumab, or certolizumab dosing interval for evidence of fistula closure and overall reduction in the number of fistulae.

• Obtain a magnetic resonance imaging procedure prior to initiation of natalizumab therapy. Monitor patients for signs of progressive multifocal leukoencephalopathy, such as mental status changes, signs of liver disease (e.g., jaundice), and hypersensitivity reactions following administration.

Abbreviations Introduced in This Chapter

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