1 / 37

The Role of the Gastroenterologist in the long term management of inflammatory bowel disease

The Role of the Gastroenterologist in the long term management of inflammatory bowel disease. Prof D BA SILK MD AGAF FRCP Imperial College London St Mary’s Campus. Incidence and prevalence of UC & C rohns D isease. Hospitals serving 250,000 population will look after.

rbueno
Download Presentation

The Role of the Gastroenterologist in the long term management of inflammatory bowel disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Role of the Gastroenterologist in the long term management of inflammatory bowel disease Prof D BA SILK MD AGAF FRCP Imperial College London St Mary’s Campus

  2. Incidence and prevalence of UC & CrohnsDisease

  3. Hospitals serving 250,000 population will look after

  4. Roles of Gastroenterology in Medical Management of IBD • Treatment of active UC • Maintenance of remission in UC • Treatment of active CD • Maintenance of remission in CD • Thiopurines • CRC surveillance • IBD and pregnancy • IBD and stress • IBD and life expectancy

  5. Medical Management of IBD • Achievement of Remission • Maintenance of Remission

  6. Medical Therapy for Active Ulcerative Colitis • 5 ASA • Corticosteroids • Thiopurines • Calcineurin inhibitors (cyclosporin and tacrolimus) • Anti-TNF therapy • Other biological Agents • Probiotics

  7. Management of Ulcerative Colitis • Proctitis • Left sided proctocolitis • Extensive colitis • Severe active ulcerative colitis

  8. Management of Active Proctitis • Mesalazine 1G suppository • Mesalazine enemas • Mesalazine suppository/enema + oral 5ASA • Mesalazine enema + topical steroid enema • Oral prednisolone • Immunosuppressants • Biologics

  9. Management of Active Left Sided Colitis • Mesalazine enema • Oral 5ASA • Mesalazine + topical corticosteroid enema • Oral corticosteroids • IV corticosteroids

  10. Management of Active Extensive Colitis • Oral 5ASA • Oral corticosteroids • Mesalazine enemas • Mesalazine + topical corticosteroids • Thiopurines • Biologics

  11. Severe Active Ulcerative Colitis Bloody diarrhoea > 6/day and any of the following • Tachycardia > 90 bpm • Fever > 37.8o C • Hb < 10.5 g/dl • ESR > 30 mm/h Patients should be admitted under the care of a multidisciplinary team including Specialist gastroenterologist Specialist colorectal surgeon • Intravenous corticosteroids • Rescue therapy (ciclosporin, tacrolumis, infliximeb, considered early (day 3) Management demands careful clinical judgement After Second European evidence based consensus in the diagnosis and management of ulcerative colitis part 2 Current Management. J Crohns and Colitis 2012; 6: 991-1030

  12. Maintenance of Remission – Ulcerative Colitis • Oral 5 ASA therapy 2.4 g/d • Topical 5 ASA 3.0 g/wk • Combination of both • Thiopurines • Early or frequent relapse • Responders to ciclosporin • Responders to anti TNF agents • Anti – TNF therapy • Failure of thiopurines • Responders to anti TNF agents • E coli strain Nissle 1917 • VSL # 3

  13. Comparison of Oral 5ASA Medications MesalazinepH sensitive polymer coating 5 ASA Sulfasalazine Sulfapyridine 5 ASA Balsalazide 4 aminobenzoyl- alanine 5 ASA Olsalazine 5 ASA 5 ASA Diazobond

  14. Formulation release characteristics of mesalazine preparations

  15. BalsalazidevsMesalazine – Maintenance & Remission in UC After Green et al APT 1998; 12: 1207

  16. Gastrointestinal pH profiles in patients with acute pan-ulcerative colitis After Raimundo, Evans, Rogers & Silk 1992

  17. Gastrointestinal pH profiles in patients with ulcerative colitis (in remission)

  18. Mesalazine non adherence in ulcerative colitis

  19. Effect of 5 ASA use on colorectal cancer (CRC) and dysplasia risk in UC • Use of 5ASA associated with a lower risk of CRC • Use of 5ASA associated with a lower risk of combined endpoint of CRC or dysplasia Velayes et al 2005 Am J Gastro; 100: 1345 - 1353

  20. Medical Management of Crohns Disease • Glucocorticosteroids • Budesonide • 5 ASA agents • Thiopurines • Biological agents

  21. Infliximab-based treatment strategy – The Sonic Trial Patients moderate to severe Crohn’s disease 508 Aza 2.5 mg/kg/d + Placebo + infliximab Aza 2.5 mg/kg/d + Infliximab Placebo infusions (0, 2, 6 then every 8 weeks) (0, 2, 6 then every 8 weeks) 30 weeks 50 weeks End points – primary • Steroid free remission (CDA < 150) • Off steroids > 3 weeks End points – secondary • Mucosal healing

  22. Steroid Free Clinical Remission

  23. Duration of Thiopurine Therapy in IBD Frazer Orchard & Jewell. Gut 2002; 50:485

  24. Duration of Thiopurine Therapy in IBD Frazer Orchard & Jewell. Gut 2002; 50:485

  25. Problems with Thiopurines • Bone marrow suppression • Lymphoma • Solid tumours • Skin cancer • Hepatitis • Hypersensitivity reactions

  26. Colorectal cancer risk in IBD • Extent histologic inflammation +pseudopolyps • Duration of disease (> 10 yrs) • Long standing extensive colitis (> 10 years disease; > 50% colon affected) • PSC • Colonic strictures Farrge et al. AGA Medical Position Statement Gastroenterology 2010; 138: 738

  27. Surveillance Colonoscopy • Baseline in all patients before 8 yrs disease • Patients with proctitis or proctosigmoiditis not considered at risk for IBD related CRC • All other patients should commence surveillance colonoscopy 1 -2 yrs after base line examination • Frequency dependent upon presence of risk factors ( 1-3 yrs) After AGA Medical Position Statement Gastroenterology 2010; 138: 738

  28. Use of chemo-preventative agents to lower risk of CRC in IBD • Mesalazine >1.2 g/d reduces risk of CRC by 81% p = 0.006 Eaden et al APT 2000 14: 145 • Thiopurines reduce risk of CRC & HGD p = 0.006 Beaugenie et al Gastroenterology 2013l 145: 166 • ? Effect of Biological Agents

  29. How “Fail-Safe” are the Recommendations? Cancers et SorrisqueAssocie aux Maladies Inflammatory Intestinales en France (CESAME) • 19,486 patients with IBD • 38.6% of CRC or HGD developed before 10 yr disease duration Beaugenie et al Gastroenterology 2013l 145: 166

  30. Treatment of IBD in Pregnancy • Majority of drugs used in IBD are safe in pregnancy • Proactive treatment for maintenance of remission advised • Active disease and not therapy pose the greatest risk to the pregnancy Caprille et al Gut 2006;55 (suppl 1): 36-58

  31. Effect of Disease Activity and Treatment of disease on Fertility in Males and Females with IBD After Heetun et al AP & T 2007; 26: 513-533

  32. Effect of Gestation on Course of IBD After Heetun et al AP & T 2007; 26: 513-533

  33. Effect of ulcerative colitis and Crohn’s disease on rates of preterm delivery and low birth weight compared to the general population Norgard et al Am J Gastroenterol. 2000; 95: 1165 -1170 Domintz et al Am J Gastroenterol. 2002; 97: 641 – 648 Fonager et al Am J Gastroenterol. 1998; 93: 2426 - 2430

  34. Chronic stress, adverse life events and depression can cause relapse in patients with IBD Bitton et al Am J Gastro 2003; 98: 2203 Mardini et al Dig Dis Sci 2004; 49: 492 Levenstein et al Am J Gastro 2000; 95: 1213 Effects of stress on inflammation in IBD mediated through changes in • Hypothalamic-pituitary-adrenal function • Bacterial-mucosal flora interactions • Activation of mucosal mast cells • Peripheral release of CRF Symptoms of IBD exacerbated by effects of stress • Gut motility • Fluid secretion After Mandsky & Rampton Gut 2005; 54: 481

  35. Predicting Relapse in Crohn’s Disease 101 Patients in Remission 14 Withdrew 37 Relapsed Risk Factors for Flare Up p value CRP 0.007 Fistulising Disease 0.04 Colitis 0.02 Perceived stress 0.0006 Low levels of stress and low avoidance behaviour had sustained remission (85% at 1 yr) After Bitton et al Gut 2008; 17: 1386

  36. Influence of Ulcerative Colitis in Life Expectancy

  37. Multidisciplinary, patient focused IBD Clinics in Secondary Care Consultant Gastroenterologist Clinical Nurse Specialist Dietitian Clinical Psychologist Silk 2013

More Related