Garrick Brown, MD. Digestive Health Specialists Tacoma Gig Harbor

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2 Garrick Brown, MD Digestive Health Specialists Tacoma Gig Harbor

3 Today s Objectives Define IBD, its potential causes and diagnosis Discuss management and treatment Discuss complementary and alternative medicine Highlight special populations Review role of diet and nutrition in IBD Answer questions

4 What are Inflammatory Bowel Diseases? Inflammatory including Crohn s disease and ulcerative colitis 1.6 million Americans 70,000 new cases each year 1 in 200 people Symptoms, course of disease, and prognosis differ from one person to the next

5 Potential Factors to Consider Environmental Exposures Genetic Factors Gut Microbiota Immune System Abnormalities

6 Spectrum of IBD Crohn s Disease Patchy, full-thickness inflammation Mouth to anus involvement Extra-intestinal manifestations Ulcerative Colitis Continuous, superficial inflammation Colon and/or rectum Extra-intestinal manifestations Indeterminate Colitis 10%-15%

7 Diagnostic Process Crohn s disease Ulcerative colitis Medical History and Physical Examination Diagnostic testing, that may include Lab tests Imaging Endoscopy Other diagnosis

8 Recognizing Symptoms of IBD Flares Diarrhea Often increased from usual course of disease Rectal bleeding Abdominal pain or cramping Low-grade fever Fatigue

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

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

11 Extra-Intestinal Manifestations Bones Arthritis of hands and feet, lower spine (e.g. Ankylosing Spondilitis) Kidneys Liver Oral ulceration Eye inflammation Skin sores (e.g. pyroderma ganrenosm, erythema nodosum)

12 Comprehensive IBD Management Minimize treatment toxicity Provide emotional support Prevent cancer Prevent/ Treat complications Reduce/ Eliminate inflammation IBD Management Goals Control symptoms Induce/ Maintain remission Improve quality of life Ensure adequate nutrition

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

14 Prescription Medications Class Aminosalicylates Corticosteroids Agents Balsalazide (Colazal, GIAZO ) Mesalamine formulations Lialda Apriso Asacol HD Rowasa Delzicol Canasa Pentasa Olsalazine (Dipentum ); Sulfasalazine (Azulfidine ) Budesonide (Entocort, UCERIS ) Methylprednisolone (Medrol ) Prednisone Prednisolone Antibiotics Ciprofloxacin (Cipro, Proquin ) Metronidazole (Flagyl ) Rifaximin (Xifaxan )

15 Prescription Medications Class Immunomodulators Agents Azathioprine (Imuran, Azasan ) Cyclosporine (Neoral ) 6-Mercaptopurine (Purinethol ) Methotrexate Tacrolimus (Prograf ) Biologic therapies Anti-TNF antibodies Adalimumab (Humira ) Certolizumab pegol (Cimzia ) Infliximab (Remicade ) Golimumab (Simponi ) Integrin Antagonist Receptors Natalizumab (Tysabri ) Vedolizumab (Entyvio TM ) Interleukin-12 and 23 Antagonist Ustekinumab (Stelarai )

16 Biosimilars Products that are highly similar to but not exact copies of biologic medicines Inflectra TM (infliximab-dyyb) has biosimilarity to Remicade (infliximab) Anti-TNF for treatment of Crohn s disease (in adults and children) and ulcerative colitis (in adults) Amjevita TM (adalimumab-atto), has biosimilarity to Humira (adalimumab), Anti-TNF for treatment of Crohn s disease and ulcerative colitis Source: nts/ucm htm - accessed 4/13/16

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

18 Types of Surgery in IBD Crohn s Disease Strictureplasty Gastrojejunostomy (upper GI) Short bowel resection Partial colectomy Proctocolectomy with end ileostomy Perianal surgery Intestinal transplantation Ulcerative Colitis Proctocolectomy (removal of the colon and rectum) With end ileostomy Restorative (ileoanal anastomosis or J pouch)

19 Complementary and Alternative Medicine What is complementary and alternative medicine (CAM)? Group of diverse medical and healthcare systems, practices and products not presently part of conventional medicine 1 Examples» Natural products (supplements, vitamins, probiotics» Mind and body medicine (meditation, acupuncture, yoga)» Massage Lack strong scientific evidence on benefits in treating inflammatory bowel diseases Not FDA-regulated Important to seek out good data to minimize potential risk Should complement, not replace, traditional therapies Tell your doctor everything you are taking 1. NCCAM publication # D347.

20 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

21 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

22 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

23 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

24 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

25 Participate in Partners Participate in groundbreaking research Propose, discuss, and vote on research questions and topics Connect your mobile health apps to better manage your disease

26 Don t Forget Clinical Trials! Clinical trials are well-organized studies that evaluate a treatment s efficacy and safety. Patients can make informed decisions to participate in a clinical trial for IBD treatment

27 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

28 Crohn s & Colitis Foundation Resources Irwin M. and Suzanne R. Rosenthal IBD Help Center M-F, 9:00 AM-5:00 PM ET Phone: info@crohnscolitisfoundation.org Brochures and factsheets: online.ccfa.org/brochures Educational webcasts:

29 Crohn s & Colitis Foundation Resources Connect with other patients Crohn s & Colitis Community website: ccfacommunity.org Support groups and Power of Two (peer mentors): /living-with-crohns-colitis /find-a-support-group/ GI Buddy: online tracking tool and mobile app New Teen Website:

30 Questions & Answers