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Exam 1: Risks of Serious Infection or Lymphoma With Anti–Tumor Necrosis Factor Therapy for Pediatric Inflammatory Bowel Disease: A Systematic Review
Clinical Gastroenterology and Hepatology 2014;12:e87–e89
CONTINUING MEDICAL EDUCATION (CME) ACTIVITIES–EXAMS 1 AND 2 CME Credits: The AGA Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AGA Institute designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)Ô. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Faculty Disclosure: In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support of Continuing Medical Education, all faculty and planning partners must disclose any relevant financial relationship(s) or other relationship(s) held within the past 12 months. The AGA Institute implements a mechanism to identify and resolve all conflicts of interest prior to delivering the educational activity to learners.
Instructions: Category 1 credit can be earned by reading the relevant articles and taking these CME examinations online at http://www. cghjournal.org/content/cme. Answers can be obtained online after completing the exam(s).
Objectives: See article for specific learning objective.
e88
CME Activity
Clinical Gastroenterology and Hepatology Vol. 12, No. 9
Exam 1: Risks of Serious Infection or Lymphoma With Anti–Tumor Necrosis Factor Therapy for Pediatric Inflammatory Bowel Disease: A Systematic Review Test ID No.: 0205
Contact Hours: 1.0
Expiration Date: September 30, 2015
Question 1: A 16-year-old female with Crohn’s disease is hospitalized with a fever (38.5 C), hypotension, and tachycardia. Her current medication regimen includes infliximab 5 mg/kg every 8 weeks, azathioprine 50 mg orally once daily, and prednisone 40 mg orally once daily, which was started 2 weeks ago for a Crohn’s flare. Her chest x-ray is normal, she has no indwelling catheters, and her physical exam reveals no localizing source of infection. She is started on IV fluids and broad spectrum antibiotics. Her blood cultures return positive for Listeria monocytogenes, and her antibiotic regimen is tailored. Of the patient’s current inflammatory bowel disease (IBD) medications, which one likely contributed the most to the development of a serious infection?
a. b. c. d.
Infliximab Azathioprine Prednisone All of these contributed equally
Question 2: The risk of death with anti–tumor necrosis factor (TNF) therapy in pediatric IBD is:
a. Largely driven by infectious complications b. Largely driven by malignant and noninfectious complications c. Higher than that seen when using anti-TNF therapy in adult IBD d. a and c e. b and c
Question 3: The mother of a 15-year-old male Crohn’s disease patient calls the clinic concerned about her son’s medications. She recently read online that infliximab has been associated with the development of lymphoma and is now worried that her son may develop cancer. The patient was diagnosed with Crohn’s disease 1 year ago, and treatment was gradually escalated to now include infliximab 5 mg/kg every 6 weeks, azathioprine 100 mg orally once daily, and mesalamine 2.4 g orally once daily. His Crohn’s disease is well controlled, and on his last clinic visit he noted that he feels the best he’s ever felt. The mother wants to know if he should stop his infliximab. What is the most appropriate response to the mother’s concerns?
a. Infliximab is associated with an increased risk for lymphoma, and we should consider stopping it now that he’s doing well b. Infliximab and azathioprine are both equally associated with an increased risk for lymphoma, and we should discuss further which of these medications he should continue c. Infliximab may not be associated with an increased risk for lymphoma at all and should be continued
September 2014
CME Activity
Question 4: After your discussion, the mother and her son elect to continue therapy with infliximab and azathioprine. They move to a new city and continue to follow up with a local gastroenterologist. Three years later, you receive a phone call from the patient’s primary gastroenterologist informing you that he’s been hospitalized with night sweats, fevers, and 40-lb weight loss. His initial computed tomography scan shows diffusely enlarged lymph nodes and a grossly enlarged liver and spleen. Tissue biopsies are suggestive of a lymphoma of T-cell origin. What was the major contributing factor to the development of a lymphoma in this patient?
a. b. c. d. e.
Infliximab use Azathioprine use Patient characteristics a and b b and c
e89
CONTINUING MEDICAL EDUCATION (CME) ACTIVITIES–EXAMS 1 AND 2 CME Credits: The AGA Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AGA Institute designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)Ô. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Faculty Disclosure: In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support of Continuing Medical Education, all faculty and planning partners must disclose any relevant financial relationship(s) or other relationship(s) held within the past 12 months. The AGA Institute implements a mechanism to identify and resolve all conflicts of interest prior to delivering the educational activity to learners.
Instructions: Category 1 credit can be earned by reading the relevant articles and taking these CME examinations online at http://www. cghjournal.org/content/cme. Answers can be obtained online after completing the exam(s).
Objectives: See article for specific learning objective.
e88
CME Activity
Clinical Gastroenterology and Hepatology Vol. 12, No. 9
Exam 1: Risks of Serious Infection or Lymphoma With Anti–Tumor Necrosis Factor Therapy for Pediatric Inflammatory Bowel Disease: A Systematic Review Test ID No.: 0205
Contact Hours: 1.0
Expiration Date: September 30, 2015
Question 1: A 16-year-old female with Crohn’s disease is hospitalized with a fever (38.5 C), hypotension, and tachycardia. Her current medication regimen includes infliximab 5 mg/kg every 8 weeks, azathioprine 50 mg orally once daily, and prednisone 40 mg orally once daily, which was started 2 weeks ago for a Crohn’s flare. Her chest x-ray is normal, she has no indwelling catheters, and her physical exam reveals no localizing source of infection. She is started on IV fluids and broad spectrum antibiotics. Her blood cultures return positive for Listeria monocytogenes, and her antibiotic regimen is tailored. Of the patient’s current inflammatory bowel disease (IBD) medications, which one likely contributed the most to the development of a serious infection?
a. b. c. d.
Infliximab Azathioprine Prednisone All of these contributed equally
Question 2: The risk of death with anti–tumor necrosis factor (TNF) therapy in pediatric IBD is:
a. Largely driven by infectious complications b. Largely driven by malignant and noninfectious complications c. Higher than that seen when using anti-TNF therapy in adult IBD d. a and c e. b and c
Question 3: The mother of a 15-year-old male Crohn’s disease patient calls the clinic concerned about her son’s medications. She recently read online that infliximab has been associated with the development of lymphoma and is now worried that her son may develop cancer. The patient was diagnosed with Crohn’s disease 1 year ago, and treatment was gradually escalated to now include infliximab 5 mg/kg every 6 weeks, azathioprine 100 mg orally once daily, and mesalamine 2.4 g orally once daily. His Crohn’s disease is well controlled, and on his last clinic visit he noted that he feels the best he’s ever felt. The mother wants to know if he should stop his infliximab. What is the most appropriate response to the mother’s concerns?
a. Infliximab is associated with an increased risk for lymphoma, and we should consider stopping it now that he’s doing well b. Infliximab and azathioprine are both equally associated with an increased risk for lymphoma, and we should discuss further which of these medications he should continue c. Infliximab may not be associated with an increased risk for lymphoma at all and should be continued
September 2014
CME Activity
Question 4: After your discussion, the mother and her son elect to continue therapy with infliximab and azathioprine. They move to a new city and continue to follow up with a local gastroenterologist. Three years later, you receive a phone call from the patient’s primary gastroenterologist informing you that he’s been hospitalized with night sweats, fevers, and 40-lb weight loss. His initial computed tomography scan shows diffusely enlarged lymph nodes and a grossly enlarged liver and spleen. Tissue biopsies are suggestive of a lymphoma of T-cell origin. What was the major contributing factor to the development of a lymphoma in this patient?
a. b. c. d. e.
Infliximab use Azathioprine use Patient characteristics a and b b and c
e89