While efficacy is about equivalent, safety is better for VDZ/UST
Need to consider the efficacy and safety profile of COMBO therapy with anti-TNFs
Immunogenicity is highest for anti-TNFs
From real world EVOLVE-UC, it doesn't matter if we start or end at anti-TNF. So we CAN try non-TNFs first without worry.
Ustekinumab used first ⬆️⬆️⬆️⬆️QALYs
How to select first biologic:
Apart from ASUC and perianal CD, the efficacy of TNFs and non-TNFs are basically the same. The non-TNFs are safer. We don't lose efficacy of TNF if we start with non-TNF.
Pyridostigmine & neostigmine
⚡️cholinesterase inhibitors
🧠pyrido should not cross the blood-brain barrier
🚽evidence in chronic idiopathic constipation and acute colonic pseudo-obstruction
🫄pregnancy class C; excreted in breastmilk
🫀cholinergic side effects, esp bradycardia
Acotiamide
⚡️inhibits cholinesterase and enhances ACh release via muscarinic receptors
🎈enhances gastric emptying and accommodation
🔥NERD & FD
🫄no safety data
💊side effects: nausea, abdominal distension, constipation
I gave a talk on inpatient bowel regimens today for the @YaleMed@YaleIMed residents and students, with additional 💎s on outpatient #constipation. Here are the slides!
💨The gut microbiota generates ~0.2L–1.5L of gas per day
💨>99%: hydrogen (H2), carbon dioxide (CO2), & methane (CH4)– *odorless*
💨foul smell of gas from <1%: sulfur–containing gases hydrogen sulfide (H2S), methanethiol (CH3SH), dimethyl sulfide [(CH3)2S] + volatile compounds
🦠bacteria in the colon ferment substrates that are not digested or absorbed in the upper GI tract (e.g. carbohydrates, proteins, fats)
🦠produce short-chain fatty acids, branched-chain fatty acids, ammonia, N-nitro compounds, phenolic and indolic compounds, and various gases