HIV treatment - Katzung Review and American guidelines Protocole

NNRTI's - No nucleotides reverse transcriptase inhibitors

PI - Protease inhibitors

Entry inhibitors

The NNRTIs bind directly to HIV-1 reverse transcriptase (Figure 49–4), resulting in allosteric inhibition of RNA- and DNA-dependent DNA polymerase. The binding site of NNRTIs is near to but distinct from that of NRTIs. Unlike the NRTI agents, NNRTIs neither compete with nucleoside triphosphates nor require phosphorylation to be active. In addition, they lack in vitro activity against HIV-2

A further limitation to use of NNRTI agents as a component of HAART is their metabolism by the CYP450 system, leading to innumerable potential drug-drug interactions (Tables 49–3 and 49–4). All NNRTI agents are substrates for CYP3A4 and can act as inducers (nevirapine), inhibitors (delavirdine), or mixed inducers and inhibitors (efavirenz, etravirine). Given the large number of non-HIV medications that are also metabolized by this pathway (see Chapter 4); drug-drug interactions must be expected and looked for.

Delavirdine has an oral bioavailability of about 85%, but this is reduced by antacids or H₂-blockers. It is extensively bound (~ 98%) to plasma proteins and has correspondingly low cerebrospinal fluid levels. Serum half-life is approximately 6 hours. Skin rash occurs in up to 38% of patients receiving delavirdine; it typically occurs during the first 1–3 weeks of therapy and does not preclude rechallenge. However, severe rash such as erythema multiforme and Stevens-Johnson syndrome have rarely been reported. Thus, pregnancy should be avoided when taking delavirdine.

Delavirdine is extensively metabolized to inactive metabolites by the CYP3A and CYP2D6 enzymes

Efavirenz can be given once daily because of its long half-life (40–55 hours). It is moderately well absorbed following oral administration (45%). Since toxicity may increase owing to increased bioavailability after a high-fat meal, efavirenz should be taken on an empty stomach. Efavirenz is principally metabolized by CYP3A4 and CYP2B6 to inactive hydroxylated metabolites; the remainder is eliminated in the feces as unchanged drug. It is highly bound to albumin (~ 99%), and cerebrospinal fluid levels range from 0.3% to 1.2% of plasma levels. The principal adverse effects of efavirenz involve the central nervous system. Dizziness, drowsiness, insomnia, and headache tend to diminish with continued therapy

Etravirine may be effective against strains of HIV that have developed resistance to first-generation NNRTIs, depending on the number of mutations present. The most common symptomatic adverse effects of etravirine are rash, nausea, and diarrea. it has many therapeutically significant drug-drug interactions

Nevirapine

The oral bioavailability of nevirapine is excellent (> 90%) and is not food-dependent. The drug is highly lipophilic and achieves cerebrospinal fluid levels that are 45% of those in plasma. Serum half-life is 25–30 hours. It is extensively metabolized by the CYP3A isoform to hydroxylated metabolites and then excreted, primarily in the urine

A single dose of nevirapine (200 mg) is effective in the prevention of transmission of HIV from mother to newborn when administered to women at the onset of labor and followed by a 2-mg/kg oral dose to the neonate within 3 days after delivery. There is no evidence of human teratogenicity. However, resistance has been documented after this single dose. Rash, usually a maculopapular eruption that spares the palms and soles, occurs in up to 20% of patients, usually in the first 4–6 weeks of therapy

Protease Inhibitors

Protease inhibitors are active against both HIV-1 and HIV-2; unlike the NRTIs, however, they do not need intracellular activation

A syndrome of redistribution and accumulation of body fat that results in central obesity, dorsocervical fat enlargement (buffalo hump), peripheral and facial wasting, breast enlargement, and a cushingoid appearance has been observed in patients receiving antiretroviral therapy. These abnormalities may be particularly associated with the use of PIs, although the recently licensed atazanavir appears to be an exception (see below). Concurrent increases in triglyceride and LDL levels, along with hyperglycemia and insulin resistance, have also been noted. The cause is not yet known.

Whether PI agents are associated with bone loss and osteoporosis after long-term use is controversial and under active investigation. PIs have been associated with increased spontaneous bleeding in patients with hemophilia A or B. All the antiretroviral PIs are extensively metabolized by CYP3A4, with ritonavir having the most pronounced inhibitory effect and saquinavir the least. It is noteworthy that the potent CYP3A4 inhibitory properties of ritonavir have been used to clinical advantage by having it "boost" the levels of other PI agents when given in combination, thus acting as a pharmacokinetic enhancer rather than an antiretroviral agent. Ritonavir boosting increases drug exposure, thereby prolonging the drug's half-life and allowing reduction in frequency; in addition, the genetic barrier to resistance is raised

Atazanavir is an azapeptide PI with a pharmacokinetic profile that allows once-daily dosing. It should be taken with a light meal to enhance bioavailability. Atazanavir requires an acidic medium for absorption and exhibits pH-dependent aqueous solubility; therefore, separation of ingestion from acid-reducing agents by at least 12 hours is recommended. Atazanavir is able to penetrate both the cerebrospinal and seminal fluids. The plasma half-life is 6–7 hours, which increases to approximately 11 hours when co-administered with ritonavir. The most common adverse effects in patients receiving atazanavir are diarrhea and nausea; vomiting, abdominal pain, headache, peripheral neuropathy, and skin rash may also occur. As with indinavir, indirect hyperbilirubinemia with overt jaundice may occur (7–8%) owing to inhibition of the UGT1A1 glucuronidation enzyme. Elevation of hepatic enzymes has also been observed, usually in patients with underlying HBV or HCV co-infection. In contrast to the other PIs, atazanavir does not appear to be associated with dyslipidemia, fat redistribution, or the metabolic syndrome. Atazanavir may be associated with electrocardiographic PR-interval prolongation, As an inhibitor of CYP3A4 and CYP2C9, the potential for drug-drug interactions with atazanavir is great (Tables 49–3 and 49–4). Atazanavir AUC is reduced by 76% when combined with omeprazole; thus, the combination is to be avoided. In addition, co-administration of atazanavir with other drugs that inhibit UGT1A1, such as indinavir and irinotecan, is contraindicated because of enhanced toxicity. Tenofovir and efavirenz should not be co-administered with atazanavir unless ritonavir is added to boost levels.

Darunavir is licensed as a PI to be co-administered with ritonavir in treatment-experienced patients with resistance to other PIs.

Symptomatic adverse effects of darunavir include diarrhea, nausea, headache, and rash. Laboratory abnormalities include dyslipidemia (though possibly less frequent than with other boosted PI regimens) and increases in amylase and hepatic transaminase levels.

Fosamprenavir is a prodrug of amprenavir that is rapidly hydrolyzed by enzymes in the intestinal epithelium. Because of its significantly lower daily pill burden, fosamprenavir tablets have replaced amprenavir capsules for adults. Fosamprenavir is most often administered in combination with low-dose ritonavir

Amprenavir is rapidly absorbed from the gastrointestinal tract, and its prodrug can be taken with or without food. However, high-fat meals decrease absorption and thus should be avoided. The plasma half-life is relatively long (7–11 hours). Amprenavir is metabolized in the liver by CYP3A4 and should be used with caution in the setting of hepatic insufficiency.

The most common adverse effects of fosamprenavir are headache, nausea, diarrhea, perioral paresthesias, depression, and rash. Up to 3% of patients may experience rashes (including Stevens-Johnson syndrome) severe enough to warrant drug discontinuation

The oral solution, which contains propylene glycol, is contraindicated in young children, pregnant women, patients with renal or hepatic failure, and those using metronidazole or disulfiram. Also, the oral solutions of amprenavir and ritonavir should not be co-administered because the propylene glycol in one and the ethanol in the other may compete for the same metabolic pathway, leading to accumulation of either. /ritonavir should not be co-administered with amprenavir owing to decreased amprenavir and increased lopinavir exposures.

Indinavir requires an acidic environment for optimum solubility and therefore must be consumed on an empty stomach or with a small, low-fat, low-protein meal for maximal absorption (60–65%). The serum half-life is 1.5–2 hours, protein binding is approximately 60%, and the drug has a high level of cerebrospinal fluid penetration (up to 76% of serum levels). Excretion is primarily fecal. The most common adverse effects of indinavir are indirect hyperbilirubinemia and nephrolithiasis due to crystallization of the drug. Nephrolithiasis can occur within days after initiating therapy, with an estimated incidence of approximately 10%. Consumption of at least 48 ounces of water daily is important to maintain adequate hydration. Thrombocytopenia, elevations of serum aminotransferase levels, nausea, diarrhea, insomnia, dry throat, dry skin, and indirect hyperbilirubinemia have also been reported. Insulin resistance may be more common with indinavir than with the other PIs, occurring in 3–5% of patients. There have also been rare cases of acute hemolytic anemia. In rats, high doses of indinavir are associated with development of thyroid adenomas.

Lopinavir should be taken with food to enhance bioavailability. The drug is highly protein bound (98–99%), and its half-life is 5–6 hours. Lopinavir is extensively metabolized by CYP3A, which is inhibited by ritonavir. The most common adverse effects of lopinavir are diarrhea, abdominal pain, nausea, vomiting, and asthenia. Elevations in serum cholesterol and triglycerides are common. Increased dosage of lopinavir/ritonavir is recommended when co-administered with efavirenz or nevirapine, which induce lopinavir metabolism. There is no evidence of human teratogenicity of lopinavir/ritonavir; short-term safety in pregnant women has been demonstrated for mother and infant.

Nelfinavir has high absorption in the fed state (70–80%), undergoes metabolism by CYP3A, and is excreted primarily in the feces. The plasma half-life in humans is 3.5–5 hours, and the drug is more than 98% protein-bound.

The most common adverse effects associated with nelfinavir are diarrhea and flatulence

Ritonavir has a high bioavailability (about 75%) that increases with food. It is 98% protein-bound and has a serum half-life of 3–5 hours. Metabolism to an active metabolite occurs via the CYP3A and CYP2D6 isoforms. Potential adverse effects of ritonavir, particularly when administered at full dosage, are gastrointestinal disturbances, paresthesias (circumoral or peripheral), elevated serum aminotransferase levels, altered taste, headache, hypertriglyceridemia, hypercholesterolemia, and elevations in serum creatine kinase

its original formulation as a hard gel capsule (saquinavir-H; Invirase), oral saquinavir is poorly bioavailable (only about 4% after food). However, reformulation of saquinavir-H for once-daily dosing in combination with low-dose ritonavir has both improved antiviral efficacy and decreased gastrointestinal adverse effects.

Saquinavir should be taken within 2 hours after a fatty meal for enhanced absorption. Saquinavir is 97% protein-bound, and serum half-life is approximately 2 hours.

Tipranavir is a newer PI for treating patients with resistance to other PI agents. Bioavailability is poor but is increased when taken with a high-fat meal. The most common adverse effects from tipranavir are diarrhea, nausea, vomiting, abdominal pain, and rash (urticarial or maculopapular); the latter may be accompanied by systemic symptoms or desquamation. Tipranavir should be discontinued in patients with increased serum transaminase levels to more than 10 times the upper limit of normal. Because of an increased risk for intracranial hemorrhage in patients receiving tipranavir, the drug should be avoided in patients with head trauma or bleeding diathesis. Other potential adverse effects include depression; elevations in total cholesterol, triglycerides, and amylase. Tipranavir both inhibits and induces the CYP3A4 system. When used in combination with ritonavir, its net effect is inhibition.

Entry inhibitors: Enfuvirtide is a synthetic 36-amino-acid peptide fusion inhibitor that blocks entry into the cell (Figure 49–4). Enfuvirtide, binds to the gp41 subunit of the viral envelope glycoprotein, preventing the conformational changes required for the fusion of the viral and cellular membranes. It has no activity against HIV-2. Enfuvirtide must be administered by subcutaneous injection. Metabolism appears to be by proteolytic hydrolysis without involvement of the CYP450 system. Elimination half-life is 3.8 hours.

Maraviroc binds specifically and selectively to CCR5, one of two coreceptors necessary for entrance of HIV into CD4+ cells, thus blocking entry of CCR5-tropic HIV into these cells. Maraviroc is to be used in adults with CCR5-tropic (also known as R5) HIV-1 infection that are experiencing virologic failure due to resistance to other antiretroviral agents. Studies have shown that 52–60% of patients in whom at least two antiviral regimens had failed were infected with R5 HIV. Since maraviroc is active against HIV that uses the CCR5 coreceptor exclusively, and not against HIV strains with CXCR4, dual, or mixed tropism, tropism testing should be performed before initiating treatment with maraviroc.

The absorption of maraviroc is rapid but variable, with the time to maximum absorption generally being 1–4 hours after ingestion of the drug. There appears to be no cross-resistance with drugs from any other class, including the fusion inhibitor enfuvirtide. However, virologic failure of regimens containing maraviroc may potentially be caused not only by resistance but also by emergence of non–CCR5-tropic virus (eg, CXCR4-tropic virus) or by changes in viral tropism, owing to the development of multiple mutations throughout gp160. Maraviroc is a substrate for CYP3A4 and therefore requires adjustment in the presence of drugs that interact with these enzymes. Absolute bioavailability of raltegravir has not been established but does not appear to be food-dependent. The drug is metabolized by glucuronidation and does not interact with the cytochrome P450 system

American Guideline Protocole (Choose at least one option from red and blue)

Efavirenz OR ( Ritonavir + (Atazanavir OR Fosamprenavir OR Saquinavir)) + ((Emtricitabine OR Lamivudine) + (Abacavir OR Tenofovir))

NRTI's - Antiretroviral therapy in HIV - Katzung Review and American Guidelines Review

Nucleotides Reverse Transcriptase Inhibitors (NRTI's)

Lamivudine or emtricitabine therapy tends to select rapidly for the M184V mutation in regimens that are not fully suppressive; however, although this mutation confers reduced susceptibility to abacavir, didanosine, and zalcitabine, its presence may restore phenotypic susceptibility to zidovudine. The K65R mutation is associated with reduced susceptibility to tenofovir, abacavir, lamivudine, and emtricitabine.

All NRTIs may be associated with mitochondrial toxicity, probably owing to inhibition of mitochondrial DNA polymerase gamma. Less commonly, lactic acidosis with hepatic steatosis may occur, which can be fatal. NRTI treatment should be suspended in the setting of rapidly rising aminotransferase levels, progressive hepatomegaly, or metabolic acidosis of unknown cause. The thymidine analogues zidovudine and stavudine may be particularly associated with dyslipidemia and insulin resistance. Also, recent evidence suggests an increased risk of myocardial infarction in patients receiving abacavir or didanosine; this bears further investigation.

Abacavir is a guanosine analog (Figure 49–2) that is well absorbed following oral administration (83%) and is unaffected by food. The serum half-life is 1.5 hours; the intracellular half-life of 3.3 hours necessitates twice-daily dosing. The drug undergoes hepatic glucuronidation and carboxylation. Cerebrospinal fluid levels are approximately one third those of plasma.

Abacavir is often co-administered with lamivudine, and a combination formulation is available.

High-level resistance to abacavir appears to require at least two or three concomitant mutations and thus tends to develop slowly.

Hypersensitivity reactions, occasionally fatal, have been reported in 3–5% of patients receiving abacavir. Symptoms, which generally occur within the first 6 weeks of therapy, include fever, malaise, nausea, vomiting, diarrhea, and anorexia. Respiratory symptoms such as dyspnea, pharyngitis, and cough may also be present, and skin rash occurs in about 50% of patients. Abacavir should be used cautiously in patients with existing cardiac risk factors due to a possible increased risk of myocardial events.

Didanosine (ddI) is a synthetic analog of deoxyadenosine (Figure 49–2). Oral bioavailability is approximately 40%; dosing on an empty stomach is optimal, but buffered formulations are necessary to prevent inactivation by gastric acid (Table 49–3). Cerebrospinal fluid concentrations of the drug are approximately 20% of serum concentrations. Serum half-life is 1.5 hours, but the intracellular half-life of the activated compound is as long as 20–24 hours. The drug is eliminated by both cellular metabolism and renal excretion.

The major clinical toxicity associated with didanosine therapy is dose-dependent pancreatitis. Other risk factors for pancreatitis (eg, alcoholism, hypertriglyceridemia) are relative contraindications, and other drugs with the potential to cause pancreatitis, including zalcitabine, stavudine, and hydroxyurea, should be avoided (Table 49–3). Other reported adverse effects include peripheral distal sensory neuropathy, diarrhea (particularly with the buffered formulation), hepatitis, esophageal ulceration, cardiomyopathy, central nervous system toxicity (headache, irritability, insomnia), and hypertriglyceridemia. Asymptomatic hyperuricemia may precipitate attacks of gout in susceptible individuals.

Emtricitabine (FTC) is a fluorinated analog of lamivudine with a long intracellular half-life (> 24 hours), allowing for once-daily dosing (Figure 49–2). Oral bioavailability of the capsules is 93% and is unaffected by food, but penetration into the cerebrospinal fluid is low. Elimination is by both glomerular filtration and active tubular secretion. The serum half-life is about 10 hours.

The oral solution, which contains propylene glycol, is contraindicated in young children, pregnant women, patients with renal or hepatic failure, and those using metronidazole or disulfiram. The most common adverse effects observed in patients receiving emtricitabine are headache, diarrhea, nausea, and asthenia. In addition, hyperpigmentation of the palms and/or soles may be observed (~ 3%), particularly in blacks (up to 13%). No drug-drug interactions of note have been reported to date.

Lamivudine (3TC) is a cytosine analog (Figure 49–2) with in vitro activity against HIV-1 that is synergistic with a variety of antiretroviral nucleoside analogs—including zidovudine and stavudine—against both zidovudine-sensitive and zidovudine-resistant HIV-1 strains. Oral bioavailability exceeds 80% and is not food-dependent. In children, the mean cerebrospinal fluid:plasma ratio of lamivudine was 0.2. Serum half-life is 2.5 hours, whereas the intracellular half-life of the triphosphorylated compound is 11–14 hours. Most of lamivudine is eliminated unchanged in the urine.

Potential adverse effects are headache, dizziness, insomnia, fatigue, and gastrointestinal discomfort, although these are typically mild. Lamivudine's bioavailability increases when it is co-administered with trimethoprim-sulfamethoxazole. Lamivudine and zalcitabine may inhibit the intracellular phosphorylation of one another; therefore, their concurrent use should be avoided if possible. Short-term safety of lamivudine has been demonstrated for both mother and infant.

The thymidine analog stavudine (d4T) (Figure 49–2) has high oral bioavailability (86%) that is not food-dependent. The serum half-life is 1.1 hours, the intracellular half-life is 3.0–3.5 hours, and mean cerebrospinal fluid concentrations are 55% of those of plasma

The major dose-limiting toxicity is a dose-related peripheral sensory neuropathy. The incidence of neuropathy may be increased when stavudine is administered with other neuropathy-inducing drugs such as didanosine and zalcitabine, or in patients with advanced immunosuppression. Lactic acidosis with hepatic steatosis, as well as lipoatrophy, appear to occur more frequently in patients receiving stavudine than in those receiving other NRTI agents. Moreover, because the co-administration of stavudine and didanosine may increase the incidence of lactic acidosis and pancreatitis, concurrent use should be avoided. This combination has been implicated in several deaths in HIV-infected pregnant women

TEnofoviR: Like the nucleoside analogs, tenofovir competitively inhibits HIV reverse transcriptase and causes chain termination after incorporation into DNA. However, only two rather than three intracellular phosphorylations are required for active inhibition of DNA synthesis.

Tenofovir disopoxilfumarate is a water-soluble prodrug of active tenofovir. The oral bioavailability in fasted patients is approximately 25% and increases to 39% after a high-fat meal. The prolonged serum (12–17 hours) and intracellular half-lives allow once-daily dosing. Elimination occurs by both glomerular filtration and active tubular secretion.

Tenofovir is often co-administered with emtricitabine, and a combination formulation is available. Gastrointestinal complaints (eg, nausea, diarrhea, vomiting, flatulence) are the most common adverse effects but rarely require discontinuation of therapy. Tenofovir-associated proximal renal tubulopathy causes excessive renal phosphate and calcium losses and 1-hydroxylation defects of vitamin D. Tenofovir is associated with decreased fetal growth and reduction in fetal bone porosity in monkeys. There is significant placental passage in humans.

Zalcitabine (ddC) is a cytosine analog with high oral bioavailability (87%) and a serum half-life of 1–2 hours. Intracellular half-life of 2.6 hours necessitates thrice-daily dosing, which limits its usefulness (Figure 49–2). Plasma levels decrease by 25–39% when the drug is administered with food or antacids. The drug is excreted renally. Cerebrospinal fluid concentrations are approximately 20% of those in the plasma.

Zalcitabine therapy is associated with a dose-dependent peripheral neuropathy that can be treatment-limiting in 10–20% of patients but appears to be slowly reversible if treatment is stopped promptly. The other major reported toxicity consists of oral and esophageal ulcerations. Pancreatitis occurs less frequently than with didanosine administration, but co-administration of other drugs that cause pancreatitis may increase the frequency of this adverse effect. The AUC of zalcitabine increases when co-administered with probenecid or cimetidine, and bioavailability decreases with concurrent antacids or metoclopramide. Lamivudine inhibits the phosphorylation of zalcitabine in vitro, potentially interfering with its efficacy

Zidovudine (azidothymidine; AZT) is a deoxythymidine analog (Figure 49–2) that is well absorbed (63%) and distributed to most body tissues and fluids, including the cerebrospinal fluid, where drug levels are 60–65% of those in serum. Although the serum half-life averages 1.1 hours, the intracellular half-life of the phosphorylated compound is 3–4 hours, allowing twice-daily dosing. Zidovudine is eliminated primarily by renal excretion following glucuronidation in the liver.

In pregnancy (Table 49–5), a regimen of oral zidovudine beginning between 14 and 34 weeks of gestation, intravenous zidovudine during labor, and zidovudine syrup to the neonate from birth through 6 weeks of age has been shown to reduce the rate of vertical (mother-to-newborn) transmission of HIV by up to 23%

Ulcerative colitis - Chrons disease

Ulcerative colitis

Inflammatory bowel disease is thought to result

from inappropriate and ongoing activation of the mucosal

immune system driven by the presence of normal

luminal flora.

the absolute risk of inflammatory bowel disease

is approximately 7 percent among first-degree

family members. Collectively, these findings lend compelling support

to the inference that susceptibility is inherited

and that the genetic contribution to the development

of disease is more important in Crohn’s disease than

in ulcerative colitis.

This gene encodes

a cytoplasmic protein designated NOD2 (also referred

to as CARD 15 [caspase activation and recruitment

domain]), which is expressed in macrophages and may

serve as a so-called pattern-recognition receptor for

bacterial lipopolysaccharide, perhaps regulating nuclear

factork B activation and macrophage apoptosis.

“only” 45 percent of pairs

of identical twins are concordant for Crohn’s disease. early appendectomy, which is associated with a reduced incidence of ulcerative colitis. Smoking may

modify the phenotype; it protects against ulcerative

colitis but increases the risk of Crohn’s disease.

Rta immune: In contrast, the mucosa in patients with ulcerative colitis

may be dominated by CD4+ lymphocytes with an

atypical type 2 helper-T-cell (Th2) phenotype, characterized by the production of transforming growth factorb(TGFb) and interleukin-5 but not interleukin-4

The activation of central immune-cell populations

is eventually accompanied by the production of a wide

variety of nonspecific mediators of inflammation (Fig.

2). These include many other cytokines, chemokines,

and growth factors as well as metabolites of arachidonic

acid (e.g., prostaglandins and leukotrienes) and

reactive oxygen metabolites such as nitric oxide. T_H2 cells and related natural killer T cells that secrete IL-13 induce superficial mucosal inflammation resembling UC, and T_H17 cells may be responsible for neutrophilic recruitment. in an IBD patient, the normal flora is likely perceived as if it were a pathogen. Anaerobic organisms, particularly Bacteroides and Clostridia species, and some aerobic species such as Escherichia may be responsible for the induction of inflammation.

UC is a mucosal disease that usually involves the rectum and extends proximally to involve all or part of the colon. About 40–50% of patients have disease limited to the rectum and rectosigmoid, 30–40% have disease extending beyond the sigmoid but not involving the whole colon, and 20% have a total colitis. Proximal spread occurs in continuity without areas of uninvolved mucosa. When the whole colon is involved, the inflammation extends 1–2 cm into the terminal ileum in 10–20% of patients. This is called backwash ileitis and is of little clinical significance. Although variations in macroscopic activity may suggest skip areas, biopsies from normal-appearing mucosa are usually abnormal. Thus, it is important to obtain multiple biopsies from apparently uninvolved mucosa, whether proximal or distal, during endoscopy.

With mild inflammation, the mucosa is erythematous and has a fine granular surface that looks like sandpaper. In more severe disease, the mucosa is hemorrhagic, edematous, and ulcerated (Fig. 289-1). In long-standing disease, inflammatory polyps (pseudopolyps) may be present as a result of epithelial regeneration. The mucosa may appear normal in remission, but in patients with many years of disease it appears atrophic and featureless and the entire colon becomes narrowed and shortened. Patients with fulminant disease can develop a toxic colitis or megacolon where the bowel wall thins and the mucosa is severely ulcerated; this may lead to perforation.

Clinical

The major symptoms of UC are diarrhea, rectal bleeding, tenesmus, passage of mucus, and crampy abdominal pain. The severity of symptoms correlates with the extent of disease. Although UC can present acutely, symptoms usually have been present for weeks to months. Occasionally, diarrhea and bleeding are so intermittent and mild that the patient does not seek medical attention. Patients with proctitis usually pass fresh blood or blood-stained mucus, either mixed with stool or streaked onto the surface of a normal or hard stool. They also have tenesmus, or urgency with a feeling of incomplete evacuation, but rarely have abdominal pain. With proctitis or proctosigmoiditis, proximal transit slows, which may account for the constipation commonly seen in patients with distal disease. When the disease extends beyond the rectum, blood is usually mixed with stool or grossly bloody diarrhea may be noted. Colonic motility is altered by inflammation with rapid transit through the inflamed intestine. When the disease is severe, patients pass a liquid stool containing blood, pus, and fecal matter. Diarrhea is often nocturnal and/or postprandial. Although severe pain is not a prominent symptom, some patients with active disease may experience vague lower abdominal discomfort or mild central abdominal cramping. Severe cramping and abdominal pain can occur with severe attacks of the disease. Other symptoms in moderate to severe disease include anorexia, nausea, vomiting, fever, and weight loss.

Ulcerative Colitis

Patients with long-standing UC are at increased risk for developing colonic epithelial dysplasia and carcinoma (Fig. 289-9).

The risk of neoplasia in chronic UC increases with duration and extent of disease. The risk of cancer rises 0.5–1% per year after 8–10 years of disease in patients with pancolitis. The only prospective surveillance study reported a lower rate of cancer; 2.5% at 20 years of disease, 7.6% at 30 years of disease, and 10.8% at 40 years. The rates of colon cancer are higher than in the general population, and colonoscopic surveillance is the standard of care