Inflammatory Bowel Disease

Thank you to Dr Ehrlich for a very insightful lecture on Inflammatory Bowel Disease (IBD)!

Click here for the lecture powerpoint!

See Lecture Video Database for the lecture recording (coming soon).

Epidemiology

  • 1.4 million people in US
  • Urban population
  • Northern climates
  • Bimodal age incidence distribution
    • 15-30 yo
    • 50-65 yo
  • No known dietary triggers. So for the most part patients can eat whatever they want.

Disease Characteristics

  • See powerpoint Slide #5 for table describing differences between UC and Crohn’s.
  • Note: Patients are at increased risk of cancer due to chronic inflammation

Medications for Ulcerative Colitis (UC)

Topical Medications

  • 5asa suppository or enema
  • Steroid suppository, foam, enema

Oral Medications

  • 5-ASA
  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Cyclosporine (rarely used anymore)
  • Methotrexate
  • Biologics (Anti TNF alpha inhibitors):
    • Infliximab (IV infusion)
    • Adalimumab (SC injection)
    • Golimumab: similar to the other drugs on the market
  • Budesonide MMX: newer agent; tablet that only gets released when it hits the colon. For mild to moderate UC. Use as an adjunct to 5asa to get pt back in remission

Treatment Strategy:

  • Combination oral and topical initially. Then just oral when it’s better controlled
    Avoid steroids if possible

Medications for Crohn’s Disease

Topical Medications

  • Only useful in Crohn’s Colitis.

Oral Medications

  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Antibiotics
  • Methotrexate as adjunct
  • Biologics (anti TNF alpha: Infliximab (IV infusion),  Adalimumab (SC injection)
  • Natalizumab: causes pml so not used anymore
  • Vedolizumab: antibiotics integrin prevents leukocyte tracking. Similar to natalizumab, but specific to the gut. No PML so far. IV on weeks 0, 2, 6 and every 8 weeks thereafter
  • More effective in UC compared to crohn’s
  • Ustekinumab (Stelara) il 23 inhibitor, previously approved for psoriasis. Note at a higher dose for crohn’s.
  • Check out the Uniti1 and Uniti2 Trials for more information

Health Maintenance in IBD Patients

Vaccines in Immunosuppressed Patients

As is inherent in the term, the immune response is blunted with immunosuppressives and thus live vaccines are contraindicated.  BUT, there is no evidence that giving a vaccine will cause an IBD flare.

Definition of immunosuppression:

  • Prednisone 20mg daily for two or more weeks and within three months of discontinuation
  • Treatment with immunomodulators or biologics and within three months of discontinuation
  • Significant protein/calorie malnurition

And other vaccines are contraindicated in immunosuppressives

Inactivated vaccines are able to be given in immunosuppression:

  • Ex: TDaP, HPV, Influenza, Hepatitis A, Hepatitis B, Pneumococcal

Live vaccines should NOT be given in immunosuppression:

  • Ex: Varicella, Herpes Zoster, MMR

Bone Health in IBD

Assess bone density (via DEXA) in the following conditions:

  • Total steroid use >3 months
  • Inactive disease but past chronic steroid use of at least 1 year but within the last 2 years
  • Inactive disease but maternal history of osteoporosis
  • Inactive disease but malnourished or very thin
  • Inactive disease but amenorrheic
  • Post menopausal women regardless of disease status

Skin exam yearly if on immunosuppressed

Colonoscopy and Cancer Screening in IBD

  • IBD with greater than 1/3 of colon affected? If yes, then start colon cancer screening 8 to 10 years after initial diagnosis. Then, screen every 1-2 years.
    • Chromoendoscopy preferred
  • Tobacco cessation
    Depression screening

Tidbits on Medications

  • 5-ASA: commonly causes renal insufficiency (check once yearly Cr)
  • Immunomodulators (AZA, 6MP, MTX): monitor for blood and liver abnormalities;  cancer(lymphoma), pancreatitis
    • Check these tests weekly for a monthly then space out
  • Anti-TNF alpha: Check HBV and TB before initiation

IBD during Pregnancy

  • MTX absolutely contraindicated
  • Sulfasalazine causes reversible azoospermia in men
  • Key Point: Keep sxs controlled. Most meds can be continued during pregnancy