Understanding Inflammatory Bowel Diseases (IBD):

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2 Understanding Inflammatory Bowel Diseases (IBD): What Every Patient Needs to Know William H Holderman, MD Digestive Health Specialists Tacoma, WA

3 Today s Objectives Define IBD, its potential causes and diagnosis Discuss management and treatment Highlight special populations Review latest research Answer questions

4 What Is IBD? Comprises Crohn s disease (CD) and ulcerative colitis (UC) Overlapping symptoms and complications Crohn s disease can affect any area of the gastrointestinal (GI) tract, including the small intestine and colon UC affects only the colon An estimated 1.4 million Americans live with IBD 30,000 new cases diagnosed each year

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6 IBD vs IBS IBS IBD Abdominal pain Cramping Altered stool pattern can be diarrhea constipation or both May report bleeding, usually normal HCT Usually no weight loss All labs usually normal Normal colonoscopy, normal imaging abdominal pain cramping usually diarrhea, but may have constipation bleeding with UC weight loss w/ Crohn s anemia, low albumin abnormal findings imaging abnormal colonoscopy

7 Inflammatory Bowel Disease Age of Onset

8 What Are the Potential Causes of IBD? Genetic Predisposition 20% 25% of patients have a close relative with IBD Environmental Factors Infections, antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), diet, smoking Immune System Abnormalities An inappropriate reaction by the body s immune system

9 Smoking in IBD Ulcerative Colitis Smoking can protect against UC Ex-smokers are more likely to develop UC Crohn s disease Twofold risk in current smokers Smokers are less responsive to treatment Smokers are more likely to develop recurrence of disease after surgery

10 The Spectrum of IBD CROHN S DISEASE Patchy inflammation Mouth to anus involvement Full-thickness inflammation Variable involvement Fistulas Abscesses Strictures Extraintestinal manifestations Increased risk of cancer Indeterminate colitis 10% 15% ULCERATIVE COLITIS Continuous inflammation Colon only Superficial inflammation Variable involvement Increased risk of cancer Extraintestinal manifestations

11 Ulcerative Colitis Proctitis Left-sided Colitis Total Colitis Small Intestine Not Involved

12 Crohn s Disease Anatomic Distribution ) Colon alone (20%)

13 Understanding Complications of Ulcerative Colitis Anemia from blood loss Perforation (rupture) of the bowel Colorectal cancer Toxic megacolon Perforation

14 Understanding Complications of Crohn s Disease Obstruction Intestinal obstruction Abscess Fistula Stricture Colorectal cancer Fistula

15 % Recurrence Postsurgical Recurrence of CD Years Radiologic/Endoscopic recurrence Symptomatic recurrence McLeod RS et al. Gastroenterology. 1997;113:1823.

16 Diagnosing IBD

17 Recognizing Symptoms of IBD Flares Diarrhea Often increased from usual course of disease Rectal bleeding Abdominal pain or cramping Low-grade fever Fatigue Extraintestinal manifestations Joint pain/swelling Eye inflammation Skin lesions Mouth ulcers

18 C-difficile in IBD patients

19 Diagnosing IBD Normal colon on colonoscopy UC on colonoscopy CD on colonoscopy

20 Management & Treatment of IBD

21 Comprehensive IBD Management Provide emotional support Prevent cancer Improve quality of life Replenish nutritional deficits IBD Management Goals Maintain steroid free remission Control symptoms Treat inflammation Treat complications Minimize treatment toxicity

22 Understanding Treatment Options Prescription medications Over-the-counter agents Complementary and alternative therapies Surgery

23 Prescription Medications Class Agents 5-ASA Agents Balsalazide (Colazal ) Mesalamine formulations Delayed release tablets (Lialda, Asacol, Asacol HD ) Controlled release tablets (Pentasa ) Extended release capsules (Apriso ) Rectal suspension (Rowasa ) Rectal suppository (Canasa ) Olsalazine (Dipentum ); Sulfasalazine (Azulfidine ) Corticosteroids Adrenocorticotropic hormone Budesonide (Entocort, Uceris) Hydrocortisone (Cortenema, Cortifoam ) Methylprednisolone (Medrol ) Prednisone Antibiotics Ciprofloxacin (Cipro ) Metronidazole (Flagyl ) Rifaximin (Xifaxin )

24 Prescription Medications Class Agents Immunologic Agents Azathioprine (Imuran, Azasan ) Cyclosporine (Neoral ) 6-Mercaptopurine (Purinethol ) Methotrexate Tacrolimus (Prograf ) Biologic Agents Adalimumab (Humira ) Certolizumab pegol (Cimzia ) Infliximab (Remicade ) Natalizumab (Tysabri ) Vedolizamab (Entyvio)

25 Stomach 5-ASA Release Sites Pentasa Asacol Azulfidine Dipentum Colazal Small Intestine Large Intestine Mesalamine in microgranules Mesalamine w/ eudragit-s Azo bond Rowasa Canasa

26 Benefits Induces remissions in UC and CD Quick fix Inexpensive Oral or rectal Corticosteriods Risks No long-term benefits Numerous side effects Cushingoid changes Hypertension Diabetes Osteoporosis Acne Cataracts Depression Growth retardation

27 Immune-Modulators Imuran (azathioprine) & Purinetheol (6-MP) Myths Dangerous drugs used to treat cancer Cause cancer Should not be used longer than 3 years If they don t work over 3-6 months, they will not work Must be stopped before or during pregnancy Facts Very slight increased risk of lymphoma Can be used for more than 3 years If they don t seem to work at first, the dose needs to be reassessed Can be used during pregnancy, Must be monitored

28 Over-the-Counter (OTC) Agents Address only specific symptoms Antidiarrheal agents Laxatives Pain relievers Important to discuss with physician before taking any OTC medications

29 Complementary & Alternative Therapies: Probiotics Good bacteria that restore balance to the enteric microbiota-bacteria in the intestines May be helpful in aiding recovery of the intestine and maintaining remission Important to discuss with physician before initiating treatment

30 Surgery in IBD Crohn s Disease Strictureplasty Resection of small intestinal segment Colectomy (partial or complete) Proctocolectomy Ulcerative Colitis Proctocolectomy (removal of the colon and rectum) With ileostomy Restorative (ileoanal or J pouch) Unlike UC, CD cannot be cured with surgery Disease is cured once the colon is removed

31 Understanding the Importance of Diet & Nutrition in Managing IBD Causes of nutritional deficits Decreased intake (no desire to eat) Active disease Protein and fluid loss Decreased absorption of nutrients (when small intestine is affected by CD) Fat Vitamins Small intestine

32 Understanding the Importance of Diet & Nutrition in Managing IBD Create a food journal Eliminate problematic foods Strive for a well-balanced, healthy diet based on Hydration Electrolyte balance Continual adequate nutrient intake

33 IBD in Special Populations

34 Understanding IBD in Children & Adolescents Special considerations Ability to swallow capsules or tablets Side effects of drug therapy Risks of long-term corticosteroid use Emotional/social concerns Adherence Growth failure and need for nutritional supplementation Emotional well-being

35 Understanding IBD in Pregnant Women Special considerations IBD should be controlled before considering pregnancy Remain on most prescribed medications Well-balanced diet with vitamins, including folic acid Ongoing communication between obstetrician and gastroenterologist

36 IBD Research

37 IBD Research Genetics Several genes linked to both CD and UC Large genome-wide studies continue Biologic markers Measurable substances that may help characterize disease Clinical trials Better understand disease Develop novel therapies

38 Living Well With IBD Be compliant with medications Understand your disease and possible complications Schedule follow-up appointments Maintain a well-balanced diet Establish a support system Empower yourself with information Follow Helpful Tips handout

39 Percentage of Patients (%) Remaining in Remission Adherence Decreases Risk of Relapse 100 Adherent Nonadherent 25 0 Time (months) Adherent n = Nonadherent n = Kane et al. Am J Med. 2003;114:39-41.

40 Health Maintenance in a Crohn s Disease Patient Immunizations Therapy with steroids, immunosuppressants, and biologics increase risk of infection 1 Smoking cessation Bone density Cancer screening Smoking associated with complicated disease, need for surgery, suboptimal response to medical therapy, and postoperative recurrence Increased risk of osteoporosis 1,2 and osteopenia in IBD, particularly with steroid therapy 1,3 Colorectal cancer 1 Nonmelanoma skin cancer 1 Depression Significantly higher prevalence of major depression in IBD compared with controls 4 Image adapted from: Osteopenia: Knapp KM, et al. Case Rep Med. 2010;629020:1-4. Colorectal Cancer: Aihara H, et al. Gastroenterol Res Pract ;971383:1-5. Sinclair JA, et al. Gastroenterol Clin N Am. 2012;41: Baumgart DC, Sandborn WJ. Lancet. 2012;380: Lichtenstein GR, et al. Am J Gastroenterol. 2009;104: Graff LA, Walker JR, Bernstein CN. Inflamm Bowel Dis. 2009;15:

41 Questions & Answers