Management of Management of Inflammatory bowel Inflammatory bowel

diseasedisease

8/12/108/12/10

Management of Crohn’s diseaseManagement of Crohn’s disease

Stop smokingStop smoking Treat diarrhoea symptomatically with Treat diarrhoea symptomatically with

codeine phos or loperamide unless due to codeine phos or loperamide unless due to active diseaseactive disease

Cholestyramine 4g 1-3 times daily reduces Cholestyramine 4g 1-3 times daily reduces diarrhoea due to terminal ileal disease or diarrhoea due to terminal ileal disease or resectionresection

NSAIDs precipitate relapse - avoidNSAIDs precipitate relapse - avoid

CholestyramineCholestyramine

Treatment-resistant diarrhoea in Crohn's Treatment-resistant diarrhoea in Crohn's disease may be due to bile salt disease may be due to bile salt malabsorption. malabsorption.

Cholestyramine may be helpful. Cholestyramine may be helpful. Care must be taken to avoid taking Care must be taken to avoid taking

cholestyramine at the same time as other cholestyramine at the same time as other medication, the absorption of which may medication, the absorption of which may be impaired.be impaired.

Management of Crohn’ s DiseaseManagement of Crohn’ s Disease

5-ASA derivative less effective in Crohn’s 5-ASA derivative less effective in Crohn’s than for UCthan for UC

Ineffective for maintenance at less than 2g Ineffective for maintenance at less than 2g daily and flare ups should be treated with daily and flare ups should be treated with 4 g daily4 g daily

MesalazineMesalazine

5-aminosalycyclic acid. It is used as an alternative to 5-aminosalycyclic acid. It is used as an alternative to sulphasalazinesulphasalazine

patients who do not tolerate sulphasalazine it has been patients who do not tolerate sulphasalazine it has been shown that 5-ASA analogues are as effective as shown that 5-ASA analogues are as effective as sulphasalazine in preventing relapses of ulcerative colitis sulphasalazine in preventing relapses of ulcerative colitis

some consultants recommend mesalazine rather than some consultants recommend mesalazine rather than suphasalazine to be used men with inflammatory bowel suphasalazine to be used men with inflammatory bowel disease who wish to start a family (sulphalazine causes disease who wish to start a family (sulphalazine causes reversible infertility)reversible infertility)

SteroidsSteroids

Steroids are added if active disease is Steroids are added if active disease is unresponsive to mesalazineunresponsive to mesalazine

Review frequentlyReview frequently Taper over 8/52Taper over 8/52 Rapid withdrawal increases risk of relapseRapid withdrawal increases risk of relapse Steroids are associated with increased risk Steroids are associated with increased risk

of severe sepsis and mortality in Crohn’sof severe sepsis and mortality in Crohn’s

Management of Crohn’s diseaseManagement of Crohn’s disease

Alternatives are increasingly sought and Alternatives are increasingly sought and maintenance for longer than 3/12 avoidedmaintenance for longer than 3/12 avoided

Elemental or polymeric diets for 4-6 weeks Elemental or polymeric diets for 4-6 weeks can be a useful adjunct – take consultant can be a useful adjunct – take consultant adviceadvice

Management of Crohn’s diseaseManagement of Crohn’s disease

Other treatments –Other treatments – MetronidazoleMetronidazole AzathioprineAzathioprine MethotrexateMethotrexate InfliximabInfliximab SurgerySurgery After ileal resection check B12 levels After ileal resection check B12 levels

annually.annually.

InfliximabInfliximab

anti-TNF monoclonal antibodyanti-TNF monoclonal antibody primarily designed for the treatment of rheumatoid primarily designed for the treatment of rheumatoid

arthritisarthritis It is given by intravenous infusion at 0,2 and 6 weeks It is given by intravenous infusion at 0,2 and 6 weeks

then every 8 weeks thereafterthen every 8 weeks thereafter induces endoscopic and clinical remission in the 60% of induces endoscopic and clinical remission in the 60% of

patients with Crohn's disease that is unresponsive to patients with Crohn's disease that is unresponsive to azathioprine and steroids azathioprine and steroids

major limitations to the use of infliximab include the major limitations to the use of infliximab include the intravenous route of administration of the drug and intravenous route of administration of the drug and expense expense

Management of UCManagement of UC

5-ASA derivative mesalazine 1-2 g daily 5-ASA derivative mesalazine 1-2 g daily as maintenanceas maintenance

Dose can be increased to 2-4g daily in Dose can be increased to 2-4g daily in primary care to treat flare-upsprimary care to treat flare-ups

Topical 5-ASA derivatives are a useful Topical 5-ASA derivatives are a useful adjunct for rectal diseaseadjunct for rectal disease

Proximal constipation treated with stool Proximal constipation treated with stool bulking agents or laxativesbulking agents or laxatives

NSAIDs can precipitate relapse - avoidNSAIDs can precipitate relapse - avoid

Management of UCManagement of UC

Steroids (40mg daily + rectal) are added if Steroids (40mg daily + rectal) are added if prompt response needed or mesalazine prompt response needed or mesalazine unsuccessfulunsuccessful

Either GP or specialistEither GP or specialist Review frequently and taper over 8/52Review frequently and taper over 8/52 Consider osteoporosis preventionConsider osteoporosis prevention Cyclosporin or infliximab (anti-TNF Cyclosporin or infliximab (anti-TNF

antibody) under specialist careantibody) under specialist care

Management of UCManagement of UC

Azathioprine 3Azathioprine 3rdrd line agent line agent Specialist initiationSpecialist initiation Used for 10% of UC sufferers intolerant to Used for 10% of UC sufferers intolerant to

5-ASA derivatives5-ASA derivatives Added for recurrent attacks, 2 or more Added for recurrent attacks, 2 or more

courses of steroids per year, relapse as courses of steroids per year, relapse as steroid tapered, relapses within 6 weeks of steroid tapered, relapses within 6 weeks of stopping steroidsstopping steroids

Management of UCManagement of UC

Monitor FBC and LFT on azathioprineMonitor FBC and LFT on azathioprine Surgery – last resortSurgery – last resort

When to refer?When to refer?

For patients with diagnosis of IBD, refer For patients with diagnosis of IBD, refer back if continuing disabling symptoms back if continuing disabling symptoms despite treatment despite treatment

Worsening or new symptoms but not Worsening or new symptoms but not requiring admissionrequiring admission

Urgency of referral depends on clinical Urgency of referral depends on clinical state of patientstate of patient

GI MalignancyGI Malignancy

Patients with IBD have increased risk of GI Patients with IBD have increased risk of GI cancercancer

Crohn’s – large and small bowel cancer. Crohn’s – large and small bowel cancer. 5% develop tumour within 10 years of 5% develop tumour within 10 years of diagnosisdiagnosis

5% of patients with UC develop colonic 5% of patients with UC develop colonic cancercancer

Tends to develop at a relatively young age Tends to develop at a relatively young age – peak incidence 48yrs– peak incidence 48yrs

Other ConsiderationsOther Considerations

PsychosocialPsychosocial WorkWork EmbarassmentEmbarassment RelationshipsRelationships Body imageBody image Side effects of medicationSide effects of medication FertilityFertility

Long Term support in Primary CareLong Term support in Primary Care

MDT approachMDT approach National Association for Colitis and National Association for Colitis and

Crohn’s DiseaseCrohn’s Disease www.nacc.org.uk

References – InnovAiT September 2008References – InnovAiT September 2008

Ulcerative colitis: flares Ulcerative colitis: flares

Flares of ulcerative colitis are usually Flares of ulcerative colitis are usually classified as either mild, moderate or classified as either mild, moderate or severe:severe:

Mild:Mild: Fewer than four stools daily, with or without Fewer than four stools daily, with or without

bloodblood No systemic disturbanceNo systemic disturbance Normal erythrocyte sedimentation rate and C-Normal erythrocyte sedimentation rate and C-

reactive protein valuesreactive protein values

Ulcerative colitis: flares Ulcerative colitis: flares

ModerateModerate Four to six stools a day, with minimal systemic Four to six stools a day, with minimal systemic

disturbancedisturbance

Ulcerative colitis: flaresUlcerative colitis: flares

SevereSevere More than six stools a day, containing bloodMore than six stools a day, containing blood Evidence of systemic disturbance, e.g.Evidence of systemic disturbance, e.g. FeverFever TachycardiaTachycardia Abdominal tenderness, distension or reduced bowel soundsAbdominal tenderness, distension or reduced bowel sounds AnaemiaAnaemia HypoalbuminaemiaHypoalbuminaemia

Patients with evidence of severe disease Patients with evidence of severe disease should be admitted to hospital.should be admitted to hospital.