National Nursing Ebook Continuing Education Summaries

217 Nursing Assessment, Management and Treatment of Autoimmune Diseases

Mild to moderate disease Patients with mild to moderate disease are ambulatory, tolerate oral intake, and are without signs of toxicity, tenderness, masses, or obstruction. In mild to mod- erate disease cases, first-line treatment is 5-ASA (mesalamine). However, benefits from 5-ASA drugs appear to be limited. Several experts do not recommend us- ing them in small-bowel Crohn disease (Comerford & Durkin, 2021; Merck Man - ual, 2020a). Antidiarrheals are used to control diarrhea, but not in patients who have significant bowel obstruction (Rebar et al., 2019). Some experts prescribe antibiotics as first-line treatment, while others reserve antibiotics for patients not responding to 4 weeks of 5-ASA (Merck Manual, 2020a). The use of antibiotics is not definitive. Results from a 2019 study suggest that benefits provided by antibiotics in active Crohn’s disease are probably very mod- est. The effects of antibiotics on prevent- ing Crohn’s disease relapse are uncertain. No definitive conclusions were drawn, and more research is needed to identify the risks and benefits of antibiotic therapy in Crohn’s disease (Cochrane, 2019). Moderate to severe disease Patients are considered to have mod- erate to severe disease if they are without fistulas or abscesses but are in significant pain and have tenderness, fever, and/ or vomiting, or patients who have been non-responsive to mild disease treatment interventions (Merck Manual, 2020a). Administration of corticosteroids, either oral or parenteral, frequently provides swift relief of symptoms. Corticosteroids such as prednisone or prednisolone re- duce diarrhea, pain, and bleeding by de- creasing inflammation. If patients do not respond to corticosteroids, they must not

be maintained on these types of drugs (Comerford & Durkin, 2021; Merck Man - ual, 2020a). Aminosalicylates such as sul- fasalazine (Azulfidine) are also used to de - crease inflammation (Rebar et al., 2019). Immunosuppressants such as azathio- prine (Azasan) and mercaptopurine (Pu- rinethol) are prescribed to suppress the body’s response to antigens (Rebar et al., 2019). These types of drugs have a pos- itive impact for most patients. If immu- nosuppressant therapy does not work in patients who are not candidates for sur- gery, biologic agents such as vedolizum- ab may be used (Merck Manual, 2020a). If patients fail to respond to conventional treatment, an antitumor necrosis factor agent (infliximab) may be given (Rebar et al., 2019). Bowel obstruction is managed with na- sogastric suction and intravenous (IV) flu - ids. Obstruction in uncomplicated Crohn disease should resolve within a few days, However, failure to respond suggests a complication or other etiologies and im- mediate surgery is required (Merck Man - ual, 2020a). Fulminant disease, abscesses, fistulas Fistulas are typically treated with met- ronidazole and ciprofloxacin. If patients fail to respond within 3 to 4 weeks they may receive an immunomodulator (e.g., azathioprine). Fistulas often relapse (Mer - ck Manual, 2020a). Patients who present with toxicity, high fever, persistent vomiting, or a tender or palpable mass must be hospitalized for administration of IV fluids and antibiotics. Abscesses must be drained either per- cutaneously or surgically (Merck Manual, 2020a).

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