Generalized Pustular Psoriasis Induced by Infliximab in a Patient With Inflammatory Bowel Disease.

The incidence of anti-tumour necrosis factor (TNF)-induced psoriasiform eruptions has ranged in the literature between 0.5% and 10.9% of patients with inflammatory bowel disease (IBD). The morphology of the rash varies, with plaque psoriasis being the most common form. Generalized pustular eruption is reported in 10.2% of cases of anti-TNF-induced psoriasis. We are reporting a unique case of anti-TNF-associated psoriasiform eruption due to the severity of the rash presenting as a generalized pustular eruption in association with plaque psoriasiform rash requiring systemic therapy.

The Evolving Evidence for Therapeutic Drug Monitoring of Monoclonal Antibodies in Inflammatory Bowel Disease.

PURPOSE OF REVIEW: Biological medications are effective in inflammatory bowel disease (IBD) but adverse events, cost, and loss of response make their use challenging. Therapeutic drug monitoring (TDM) allows clinicians to more safely, effectively, and efficiently use medications. The purpose of this article is to review and summarize the most recent literature pertaining to TDM in IBD. RECENT FINDINGS: Measurement of biological drug trough levels predicts ongoing patient response and can be used to titrate the medication to be more effective and efficient. Antibodies against the medications predict loss of response and adverse events. Using both parameters can predict response to subsequent biologicals. Newer biologicals show similar characteristics to those more commonly used. Management protocols using drug and antibody levels optimize medication use and may be cost-effective. Recent evidence suggests benefit to TDM of biologicals in IBD.

Pathophysiology, diagnosis, and management of hepatic encephalopathy.

Hepatic encephalopathy (HE) is a common complication of cirrhosis of the liver. It is also extremely debilitating, with an untreated 3-year survival of only 23 %. While the exact pathophysiology of HE has yet to be elucidated, a number of contributing factors have been described. Abnormal levels and altered metabolism of ammonia play a central role. Recently, inflammation has also been identified as a contributor to HE. Improved understanding of the pathophysiology of HE is crucial, as current therapy centers on reduction of the body's ammonia load. Lactulose is the first-line therapy for HE, with some antibiotics recently showing promise for improved outcomes in patients with HE. The role of anti-inflammatory therapies has yet to be evaluated.

Recent advances on the management of patients with non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal bleeding is a common emergency associated with significant morbidity and mortality. The mainstays of therapy include prompt resuscitation, early risk stratification, and appropriate access to endoscopy. Patients with high-risk endoscopic findings should receive endoscopic hemostasis with a modality of established efficacy. The pillar of post-endoscopic therapy is acid-suppression via proton pump inhibitors (PPI), although the optimal dose and route of administration are still unclear. Post-discharge management of patients with peptic ulcers includes standard oral PPI treatment and eradication of Helicobacter pylori infection. The risk of recurrent bleeding should be carefully considered and appropriate gastroprotection should be offered when non-steroid anti-inflammatory drugs, anti-platelet agents, and/or anticoagulation need to be used. This review seeks to survey new evidence in the management of non-variceal upper gastrointestinal bleeding that has emerged in the past 3 years and put it into context with recommendations from recent practice guidelines.