Definitions. Clinical remission: Resolution of symptoms (stool frequency 3/day, no bleeding and no urgency)

Transcription

1 CROHN S DISEASE

2 Definitions Clinical remission: Resolution of symptoms (stool frequency 3/day, no bleeding and no urgency) Recurrence: The reappearance of lesions after surgical resection Endoscopic remission: Absent or minimal endoscopic lesions response: clinical improvement within 2-3 weeks of corticosteroid therapy, or up to 12 weeks of anti-tnf therapy Relapse: Flare of symptoms associated with evidence of inflammation as determined by CRP, fecal calprotectin, MR or CT enterography, endoscopy or ultrasound and absence of viral/bacterial infection Steroid-resistant: Patients who have active disease despite prednisolone of up to 0.75 mg/kg/day over a period of 4 weeks Steroid-dependent: Patients who are either -Unable to reduce steroids below the equivalent of prednisolone 10 mg/day within 3 months of starting steroids without recurrent active disease, or -Who have a relapse within 3 months of stopping steroids

3 Treatment Algorithm for Crohn s Disease Provide patients with Crohn s Disease proper education and advice on smoking cessation, drug adherence and fertility Assess extent and severity using endoscopy ± MR or CT enterography Mild ileal/ ileocolonic Moderate ileal/ ileocolonic Severe/extensive luminal disease Fistulizing disease Severe perianal disease 2 5-ASA Steroid/budenoside taper over 6-8 weeks 12 Exclude/drain abscess Clinical remission Lack of response/ worsening symptoms Re-evaluate in 2-4 weeks Anti-TNF therapy +/- AZA/6MP/MTX Re-evaluate 8-12 weeks after initiation Continue + regular follow-up Stop + follow-up consider 5-ASA if colonic disease Re-evaluate in 3-6 months Recurrent symptoms, need new course of CS, relapse when tapering CS < 10mg (steroid-dependent) or within 3-6 months of stopping CS 1. Corticosteroids (CS) taper: From 40-60mg/d to 0mg/ day over 6-8 weeks by 5-10mg/wk. 2. consider surgery/gyn consult for perineal disease consider adding 5-ASA in colonic disease as chemoprevention. Steroids/budenoside taper + start AZA/6MP/ MTX Relapse or suboptimal response Loss of response Go to Algorithm A response Consider alternative emerging therapy surgery =Consider referral to a multidisciplinary IBD servic AZA: Azathioprine MTX: Methotrexate 6MP: 6-Mercaptopurine

4 ULCERATIVE COLITIS

5 Definitions Clinical remission: Resolution of symptoms (stool frequency 3/day, no bleeding and no urgency) Endoscopic remission: Absent or minimal endoscopic lesions Relapse: Flare of symptoms (blood in stool, tenesmus, diarrhea) with or without evidence of mucosal inflammation and in the absence of concomitant infection Steroid-resistant: Patients who have active disease despite prednisolone of up to 0.75 mg/kg/day over a period of 4 weeks Steroid-dependent: Patients who are either: -Unable to reduce steroids below the equivalent of prednisolone 10 mg/day within 3 months of starting steroids, without recurrent active disease, or -Who have a relapse within 3 months of stopping steroids

6 Treatment Algorithm for Ulcerative Colitis Patient diagnosed with Ulcerative Colitis Determine severity and extent Mild to moderate left distal colitis/ proctitis Mild to moderate extensive colitis Moderate to severe extensive colitis Severe to fulminant colitis

7 Mild to Moderate Distal Colitis Proctitis Proctosigmoiditis 5-ASA suppositories for 4 to 6 weeks Oral 5-ASA (induction dose) + 5-ASA enema for 4 to 6 weeks 5-ASA suppositories maintenance dose Add topical steroid and/or oral 5-ASA Oral +/- enema 5-ASA maintenance dose Oral steroid + 5-ASA Oral + topical 5-ASA maintenance dose Oral + topical 5- ASA maintenance dose (± Azathioprine) Anti-TNF alpha Oral steroid + oral 5-ASA + rectal ASA 5-ASA: 5-aminosalicylic acid Maintenance dose 5-ASA Steroid dose induction + Azathioprine + 5-ASA Azathioprine + 5-ASA Anti-TNF alpha

8 Mild to Moderate Extensive Colitis Oral + topical 5-ASA Oral 5-ASA maintenance dose Oral steroid + oral 5-ASA 5-ASA maintenance dose Relapse Add Azathioprine Check adherence/ reassess disease activity Oral steroid (taper dose) + Azathioprine 5-ASA: 5-aminosalicylic acid

9 Moderate to Severe Extensive Colitis Oral steroid + oral 5-ASA Azathioprine + 5-ASA maintenance dose Hospital admission, IV steroid Objective response after 3-5 days Oral steroids + Azathioprine + oral 5- ASA Azathioprine (if CsA ) or Anti-TNF alpha Consult surgery Cyclosporine or Anti-TNF alpha Surgery 5-ASA: 5-aminosalicylic acid CsA: Cyclosporine

10 Severe to Fulminant Ulcerative Colitis IV steroid + initiate DVT prophylaxis + consult surgery Objective response 3 rd day Oral steroid (taper dose) + Azathioprine Anti-TNF alpha or Cyclosporine (CsA) relapse Azathioprine + 5- ASA maintenance dose Recurrence or steroid-resistant or steroid-dependent Anti-TNF alpha + 5-ASA Anti-TNF alpha or Azathioprine (if CsA) Surgery 5-ASA: 5-aminosalicylic acid CsA: Cyclosporine DVT: Deep Venous Thrombosis

11 Algorithm A: Loss of Response to 1st Anti-TNF Agent Evaluate for inflammation and complications Inflammation complication Inflammation complication Inflammation complication Inflammation complication (eg. Abscess) Consider check ADA and trough level (TL) Symptomatic treatment Specific treatment for complication Stop biologic, surgical evaluation, completely drain abscess Low ADA Low TL High ADA Low TL Low ADA Adequate TL Increase dose Increase dose and/or and/or decrease decrease interval, add interval immunomodulator or switch to 2 nd anti-tnf Switch to 2 nd anti-tnf or switch to agent from a different class ADA: Anti-Drug Antibodies TL: Trough Level