Management of Inflammatory bowel disease

1. Management of Inflammatory bowel disease 8/12/10

2. 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

3. 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.

4. 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

5. 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)

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. Management of UC • Azathioprine 3rd 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

13. Management of UC • Monitor FBC and LFT on azathioprine • Surgery – last resort

14. 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

15. 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

16. Other Considerations Psychosocial • Work • Embarassment • Relationships • Body image • Side effects of medication • Fertility

17. Long Term support in Primary Care • MDT approach • National Association for Colitis and Crohn’s Disease • www.nacc.org.uk • References – InnovAiT September 2008

18. 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 • No systemic disturbance • Normal erythrocyte sedimentation rate and C-reactive protein values

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

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