Pharmacotherapy Case Study 6: Ulcerative Colitis By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 6: Ulcerative Colitis By: Dr. Nehad Ahmed

 

Chief Complaint:

A 32-year-old female presents with a 4-week history of bloody diarrhea, abdominal cramps, and unintentional weight loss. She also complains of increased fatigue and feeling generally unwell.

Subjective Data:

History of Present Illness (HPI):

·        The patient reports experiencing watery diarrhea with blood and mucus for the past month, averaging 6-8 episodes per day.

·        The diarrhea is accompanied by crampy abdominal pain, particularly in the lower left quadrant, which improves slightly after defecation.

·        She notes a 10-pound unintentional weight loss over the past month, despite no significant changes in her diet.

·        She reports feeling fatigued throughout the day, which has worsened over the past 2 weeks. She also feels generally unwell and occasionally has a low-grade fever in the evenings.

·        No significant changes in bowel habits prior to the onset of symptoms. Denies nausea, vomiting, or any blood in vomitus.

·        The patient denies joint pain, skin rashes, or eye symptoms such as redness or pain.

Past Medical History (PMH):

·        Ulcerative Colitis (UC): Diagnosed 3 years ago, initially mild, with one previous flare-up treated with corticosteroids.

·        Iron deficiency anemia: Diagnosed 6 months ago, likely secondary to chronic blood loss from UC.

·        No prior surgeries related to UC, including colectomy.

·        No history of other gastrointestinal diseases or major surgeries.

 

Medications:

·        Mesalamine 2 g orally once daily (currently taking for UC flare).

·        Iron sulfate 325 mg orally once daily for anemia.

·        Acetaminophen 500 mg as needed for mild headaches.

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Non-smoker.

·        Drinks alcohol occasionally (2-3 drinks per week).

·        Works as a teacher, mostly sedentary lifestyle during the day but enjoys light walking in the evenings.

·        Reports increased work stress due to grading and parent-teacher meetings.

Family History:

·        Mother with a history of hypertension and type 2 diabetes.

·        No family history of inflammatory bowel disease (IBD), colorectal cancer, or autoimmune diseases.

Review of Systems (ROS):

·        Gastrointestinal: Bloody diarrhea, abdominal cramps, unintentional weight loss. Denies nausea or vomiting.

·        Cardiovascular: Denies chest pain, palpitations, or swelling in extremities.

·        Respiratory: No shortness of breath, cough, or wheezing.

·        Neurological: No headaches, dizziness, or visual changes.

·        Musculoskeletal: No joint pain, but mild fatigue.

 

Objective Data:

Vital Signs:

·        Blood Pressure: 110/70 mmHg

·        Heart Rate: 88 bpm

·        Respiratory Rate: 16 breaths/min

·        Temperature: 100.1°F (37.8°C) (low-grade fever)

·        Weight: 115 lbs (52.2 kg) (10 lbs weight loss over the last month)

·        Height: 5'4" (162 cm)

Physical Exam:

·        General: Alert, oriented, fatigued but in no acute distress. Slight pallor noted in conjunctiva.

·        Abdomen: Soft, mild tenderness in the left lower quadrant without rebound or guarding. No palpable masses or hepatosplenomegaly. Bowel sounds are normal.

·        Cardiovascular: Regular rate and rhythm, no murmurs or gallops.

·        Respiratory: Clear to auscultation bilaterally.

·        Musculoskeletal: No joint tenderness or deformities.

·        Skin: No rashes, erythema, or signs of skin changes.

Labs and Imaging:

·        Complete Blood Count (CBC):

o   Hemoglobin: 9.8 g/dL (low, indicative of anemia).

o   Hematocrit: 30% (low).

o   Platelets: 400,000/mm³ (elevated, consistent with inflammation).

o   White Blood Cell Count: 10,500/mm³ (mildly elevated, indicating inflammation).

·        Basic Metabolic Panel (BMP):

o   Normal electrolytes and renal function.

·        Liver Function Tests (LFTs):

o   Normal.

·        C-Reactive Protein (CRP): Elevated at 35 mg/L (suggesting active inflammation).

·        Stool Culture: Negative for infectious causes (e.g., bacterial, parasitic).

·        Colonoscopy: Findings consistent with Ulcerative Colitis. Severe inflammation, erythema, and ulcerations in the rectum and sigmoid colon, with continuous lesions extending proximally.

·        Abdominal X-ray: No signs of perforation or toxic megacolon. Mild bowel distension but no significant abnormal findings.

Assessment:

The patient is experiencing an active flare-up of Ulcerative Colitis, as evidenced by her clinical symptoms (bloody diarrhea, crampy abdominal pain, weight loss), lab findings (anemia, elevated CRP, elevated WBC), and endoscopic findings (severe inflammation and ulceration in the colon). The active disease is contributing to her anemia and fatigue. The low-grade fever is likely related to the inflammatory process.

Plan:

Pharmacologic Treatment:

1.     Corticosteroid Therapy (for acute flare):

o   Prednisone 40 mg orally daily for 7-10 days, then taper down slowly based on symptom improvement.

2.     5-Aminosalicylic Acid (5-ASA) Therapy:

o   Continue Mesalamine 2 g orally once daily for ongoing maintenance therapy after the acute flare is controlled.

3.     Iron Supplementation:

o   Continue Iron sulfate 325 mg orally once daily for iron deficiency anemia, with periodic follow-up of hemoglobin levels.

4.     Antidiarrheal (for symptom control, only if necessary):

o   Loperamide 2 mg orally as needed for diarrhea management (not to be used if signs of infection or fever occur).

 

Non-pharmacologic Treatment:

·        Dietary modifications: Suggest a low-residue, bland diet to minimize irritation of the colon during flare-up. Recommend smaller, more frequent meals.

·        Hydration: Encourage adequate hydration due to the risk of dehydration from diarrhea.

·        Smoking cessation: Although the patient does not smoke, if she were a smoker, it would be crucial to advise cessation due to its association with worse outcomes in UC.

·        Stress management: Advise the patient on stress reduction techniques such as yoga, meditation, or mindfulness exercises, as stress can exacerbate UC symptoms.

Monitoring and Follow-Up:

·        Follow-up in 1-2 weeks to assess the patient's response to corticosteroid therapy and improvement in diarrhea and abdominal pain.

·        Repeat CBC to monitor anemia and platelet levels in 2 weeks.

·        Stool test if symptoms worsen or persist to rule out infection.

·        Follow-up colonoscopy in 6 months or as needed based on symptom control and disease progression.

Patient Education:

·        Instruct the patient on the potential side effects of corticosteroids, including weight gain, fluid retention, and increased risk of infections, and emphasize the importance of tapering the medication once symptoms improve.

·        Discuss the role of maintenance therapy with mesalamine to reduce flare-ups and the importance of adherence to the prescribed regimen.

·        Educate the patient about recognizing symptoms of complications such as severe abdominal pain, fever, or increased bleeding, which may indicate a more severe disease course or complications like toxic megacolon or perforation.

·        Encourage the patient to track her bowel movements and any symptoms to help guide future management and ensure early intervention if needed.

 

Referral:

·        Referral to a dietitian for nutritional guidance to help with dietary changes and manage symptoms.

·        Referral to a gastroenterologist for ongoing management of ulcerative colitis and potential adjustments in therapy.

Long-Term Management:

·        Biologic therapy may be considered in the future if flare-ups continue to occur frequently or are refractory to current therapies. Options include anti-TNF agents (e.g., infliximab) or integrin inhibitors (e.g., vedolizumab).