Management of Inflammatory bowel disease 8/12/10

Management of Crohn’s disease  Stop smoking  Treat diarrhoea symptomatically with codeine phos or loperamide unless due to active disease  Cholestyramine 4g 1-3 times daily reduces diarrhoea due to terminal ileal disease or resection  NSAIDs precipitate relapse - avoid

Cholestyramine  Treatment-resistant diarrhoea in Crohn's disease may be due to bile salt malabsorption.  Cholestyramine may be helpful.  Care must be taken to avoid taking cholestyramine at the same time as other medication, the absorption of which may be impaired.

Management of Crohn’ s Disease  5-ASA derivative less effective in Crohn’s than for UC  Ineffective for maintenance at less than 2g daily and flare ups should be treated with 4 g daily

Mesalazine  5-aminosalycyclic acid. It is used as an alternative to sulphasalazine  patients who do not tolerate sulphasalazine it has been shown that 5-ASA analogues are as effective as sulphasalazine in preventing relapses of ulcerative colitis  some consultants recommend mesalazine rather than suphasalazine to be used men with inflammatory bowel disease who wish to start a family (sulphalazine causes reversible infertility)

Steroids  Steroids are added if active disease is unresponsive to mesalazine  Review frequently  Taper over 8/52  Rapid withdrawal increases risk of relapse  Steroids are associated with increased risk of severe sepsis and mortality in Crohn’s

Management of Crohn’s disease  Alternatives are increasingly sought and maintenance for longer than 3/12 avoided  Elemental or polymeric diets for 4-6 weeks can be a useful adjunct – take consultant advice

Management of Crohn’s disease  Other treatments –  Metronidazole  Azathioprine  Methotrexate  Infliximab  Surgery  After ileal resection check B12 levels annually.

Infliximab  anti-TNF monoclonal antibody  primarily designed for the treatment of rheumatoid arthritis  It is given by intravenous infusion at 0,2 and 6 weeks then every 8 weeks thereafter  induces endoscopic and clinical remission in the 60% of patients with Crohn's disease that is unresponsive to azathioprine and steroids  major limitations to the use of infliximab include the intravenous route of administration of the drug and expense

Management of UC  5-ASA derivative mesalazine 1-2 g daily as maintenance  Dose can be increased to 2-4g daily in primary care to treat flare-ups  Topical 5-ASA derivatives are a useful adjunct for rectal disease  Proximal constipation treated with stool bulking agents or laxatives  NSAIDs can precipitate relapse - avoid

Management of UC  Steroids (40mg daily + rectal) are added if prompt response needed or mesalazine unsuccessful  Either GP or specialist  Review frequently and taper over 8/52  Consider osteoporosis prevention  Cyclosporin or infliximab (anti-TNF antibody) under specialist care

Management of UC  Azathioprine 3 rd line agent  Specialist initiation  Used for 10% of UC sufferers intolerant to 5-ASA derivatives  Added for recurrent attacks, 2 or more courses of steroids per year, relapse as steroid tapered, relapses within 6 weeks of stopping steroids

Management of UC  Monitor FBC and LFT on azathioprine  Surgery – last resort

When to refer?  For patients with diagnosis of IBD, refer back if continuing disabling symptoms despite treatment  Worsening or new symptoms but not requiring admission  Urgency of referral depends on clinical state of patient

GI Malignancy  Patients with IBD have increased risk of GI cancer  Crohn’s – large and small bowel cancer. 5% develop tumour within 10 years of diagnosis  5% of patients with UC develop colonic cancer  Tends to develop at a relatively young age – peak incidence 48yrs

Other Considerations Psychosocial  Work  Embarassment  Relationships  Body image  Side effects of medication  Fertility

Long Term support in Primary Care  MDT approach  National Association for Colitis and Crohn’s Disease   References – InnovAiT September 2008

Ulcerative colitis: flares Flares of ulcerative colitis are usually classified as either mild, moderate or severe:  Mild: Fewer than four stools daily, with or without blood Fewer than four stools daily, with or without blood No systemic disturbance No systemic disturbance Normal erythrocyte sedimentation rate and C- reactive protein values Normal erythrocyte sedimentation rate and C- reactive protein values

Ulcerative colitis: flares  Moderate Four to six stools a day, with minimal systemic disturbance Four to six stools a day, with minimal systemic disturbance

Ulcerative colitis: flares  Severe More than six stools a day, containing blood More than six stools a day, containing blood Evidence of systemic disturbance, e.g. Evidence of systemic disturbance, e.g. Fever Fever Tachycardia Tachycardia Abdominal tenderness, distension or reduced bowel sounds Abdominal tenderness, distension or reduced bowel sounds Anaemia Anaemia Hypoalbuminaemia Hypoalbuminaemia  Patients with evidence of severe disease should be admitted to hospital.