Treatment Options Suresh Pola, MD Kaiser San Diego
Overview of Treatments! Medications! Diet! Complementary and Alternative Medicines! How to treat Pain
Treatment Goals and Target! Goals of Treatment should be defined by you and by your provider- together! Common goals:! control of symptoms, controlling inflammation, preventing unnecessary surgeries, minimizing use of steroids, avoiding hospitalizations, avoiding transfusions, minimizing side effects, staying cancer free, and having a good quality of life! Controlling inflammation can reduce risk of colon cancer! Come up with a treatment target
Treatment Tips! Quit smoking (could be more effective than other treatments for Crohn s disease!)! Know your medications, doses, and keep track of side effects! If you are not taking your medication, be honest with your provider so that you can come up with a mutual plan that you agree upon and that works! Take your medications as prescribed, set reminders if needed
Know the benefits and risks of medications Improves quality of life Treats diarrhea Treats pain Improves nutrition Prevents complications Prevents hospital stay Prevents surgery Prevents cancer Costs Side effects Infection Worsening symptoms Pancreatitis Cancer Unknowns
FDA Approved Medications! 5-ASA! Sulfasalazine! Mesalamines! Corticosteroids! Prednisone! Budesonide, Bud MMX! Immunomodulators! Methotrexate! 6MP and azathioprine! Anti-TNF! Infliximab! Adalimumab! Certolizumab! Anti Integrin! Natalizumab! Vedolizumab
5-Aminosalicylates (5ASAs)! oral or rectal (enema, suppository)! Exact mechanism unknown- Anti- inflammatory properties! Distant cousin to aspirin (but allergy doesn t cross react)! Approved for Mild to Moderate IBD! 2/3 of patients with UC respond to these medications! A minority of patients with Crohn s are sufficiently controlled on these medications
5-Aminosalicylates (5ASAs)! Examples: Rowasa, Canasa, Lialda, mesalamine, Asacol, Delzicol, Sulfasalazine, Colazal, Pentasa, Apriso! Site of action: Colon. (Pentasa: small intestine and colon)! Side effects (not including sulfasalazine): headache, rash, alopecia, interstitial nephritis, pericarditis, pneumonitis, hepatitis, pancreatitis, worsening diarrhea and abdominal pain! Tips:! With the exception of sulfasalazine, oral 5ASA medications can be taken once daily! These are some of our safest medications for IBD!
Corticosteroids! Intravenous (typically in hospital)! Oral: Prednisone, Budesonide (Entocort), Budesonide MMX (Uceris)! Suppository and Enema formulations
! Tip: Prednisone is a good short term bridge to a long term less side effect prone treatment approach. Always have a schedule to be tapered off! Corticosteroids! Mechanism of action: blocks inflammation including inflammatory mediators (cytokines)! Site of action:! Systemic: prednisone or IV steroid,! Topical: Budesonide: terminal ileum and right colon- Crohn s, Budesonide MMX: colon- UC,! Side effects: bruising, infection, elevation in blood pressure, behavioral changes, stretch marks, weight gain, insomnia, long term use has been associated with higher rates of death, osteoporosis, cataracts, osteonecrosis! These are uncommon in low dose budesonide formulations
Thiopurines! Examples: azathioprine (Imuran), 6MP (6-mercaptopurine)! Oral! Mechanism of action: immunosuppression- inhibits lymphocytes via inhibition of DNA synthesis! Site of action: systemic! Side effects: nausea, allergic reaction, pancreatitis, bone marrow suppression, drug induced hepatitis, infection, lymphoma, nonmelanomatous skin cancer! Tips: a low dose can help prevent your body from forming antibodies against biologic medications (anti TNF and anti integrin)
Methotrexate! Oral or Subcutaneous injection! Mechanism of action: immunosuppressant: inhibits lymphocyte proliferation (folate antagonist)! Site of action: systemic! Side effects: rash, nausea, mucositis, diarrhea, bone marrow suppression, hypersensitivity pneumonitis, elevated liver enzymes/hepatotoxicity, hepatic fibrosis, cirrhosis, must be used with 2 forms of contraception! Tips: take with folic acid 1mg daily and consider taking with an anti nausea medication. No more than 2 drinks per week! Used to treat Crohn s disease and can prevent antibodies against biologics in UC and Crohn s
Biologics! Genetically engineered from living organisms! Interfere with the body's inflammatory response by targeting specific molecular players in the process such as cytokines! Examples: Anti TNF (Tumor Necrosis Factor) & Anti Integrin
Antibodies! WHAT s an ANTIBODY? An antibody is a protein produced by the body's immune system when it detects foreign substances, called antigens! Antibodies are your bodies becoming immune to the biologic medication- rendering it ineffective and causing side effects! Strategies for preventing antibodies:! Take your medications on time; don t miss doses! For medications given as an infusion, ask your provider about premedications with a steroid, Tylenol, and Benadryl! Ask your doctor about adding a 6MP, azathioprine, or methotrexate
Anti-TNFs! Examples: IV: Remicade (infliximab); SubQ injection: Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)! Used in moderate and severe IBD! Mechanism of action: binds and inhibits tumor necrosis factor alpha, reducing inflammation and altering immune response! Site of action: systemic! Side effects: infusion reactions, delayed hypersensitivity reactions, new or worsening heart failure, injection site reactions, autoantibody formation, drug- induced lupus, demyelinating disorders, Non Hodgkins lymphoma, infection (including but not limited to tuberculosis, histoplasmosis, coccidiomycosis, listeriosis)
Getting the most out of your anti TNF! anti TNFs are most effective when used in combination with a thiopurine (azathioprine, 6MP)! Know your strategies to prevent antibodies! If your anti TNF isn t working and you still have inflammation in the bowel think of why this and ask your provider about checking a drug level and antibody (Remicade and Humira)! Non responder! Inadequate dose! Antibody formation
Which anti TNF should I take?! This decision should be individualized but a few thoughts:! Simponi not approved for Crohn s, Cimzia not FDA approved for UC! Insurance premiums! Convenience of IV vs. SubQ! Ability to check levels and antibody (Remicade, Humira)! Pregnancy consideration (Cimzia)! Severe colitis prefer Remicade
Anti Integrin! Examples: Tysabri (natalizumab)- Crohn s, Entyvio (vedolizumab)- UC and Crohn s! Mechanism of action of Entyvio: to block inflammatory cells (lymphocytes) from migrating into the intestine. Tysabri is not gut specific! Site of action: intestine! Side effects: runny nose/sore throat (nasopharyngitis), infection, elevated liver tests! Tips: use strategies to prevent antibodies
How long you will need to take the medications! High chance of flaring if stop infliximab (>40% in 1 year)! The answer is never forever. Forever is a long time! Yearly re-evaluation! Re-evaluate goals! Re-evaluate new knowledge on the medications! Are there new medications with better results or less side effects?! Important to not lose a medication that works! Starting and stopping could make the medication less likely to work
What can I eat?! If there is a narrowing or blockage in the bowel: use a low residue diet (avoiding roughage and foods high in fiber)! Many fad diets and other diets have anecdotal evidence! To date, Western medicine does not support any particular dietary modification for IBD.! Food in general is mildly irritating to Crohn s disease! IV nutrition or elemental diets are better for Crohn s but are not practical! Exclusion diets have not yielded any specific exclusion diet that is helpful.! Bottom line: Unless you have a blockage, eat a healthy balanced diet that doesn t cause pain and avoid what does cause pain! Important not to restrict calories when the disease is active
Complementary and Alternative Medicines (CAM)! A group of diverse medical and healthcare systems, practices, and products that are not presently considered part of conventional medicine
Complementary and Alternative Medicines (CAM)! Mind-Body Medicine, Manipulative and Body-Based Practices, Energy Medicine! Biologically-Based Practices- many are not FDA approved! Although dietary supplement manufacturers must register their facilities with FDA,* they are not required to get FDA approval before producing or selling dietary supplements! Vitamins! Supplements! Probiotics! http://www.fda.gov/food/dietarysupplements/default.htm
Probiotics! Probiotics are live bacteria that are used to restore the balance of these good bacteria in the body.! Available in the form of dietary supplements (capsules, tablets, and powders) or foods! Little evidence to support use in Crohn s disease! Evidence supports the use of VSL#3 in ulcerative colitis and pouchitis- helps with symptoms, not sure if it helps with healing! Taking probiotics is generally safe
Fish Oils! Omega-3 fatty acids found in fatty fish such as salmon, mackerel, herring, and sardines as well as some nuts and green vegetables provide an anti-inflammatory effect! It has been suggested that they may also help to relieve the intestinal inflammation of Crohn s disease and ulcerative colitis! Several studies evaluating omega-3 fatty acids have yielded conflicting findings.! I do not recommend it based on current research
Other interesting CAM! Aloe vera gel! Boswellia! Bromelain! Curcumin! Ginger
Bottom line on CAMs.! Just because it is natural does not mean it is safe! Some herbals can actually worsen IBD symptoms! Discuss CAM with your provider! Would consider CAM as supplementary rather than the only therapy
Multiple choice! Which of the following was originally extracted from willow bark! A) mesalamine! B) prednisone! C) omega 3! D) Boswellia
Multiple choice! Which of the following was originally extracted from willow bark! A) mesalamine! B) prednisone! C) omega 3! D) Boswellia
How to treat the pain! Step #1: identify the cause of the pain: not all pain is IBD related! Step #2: Treat the underlying cause! Intestinal inflammation?! Blockage?! Medication side effect?! Step #3: If medication for IBD isn t working and the pain is ongoing, assess why the medicine isn t working, consider switching the medication, consider surgery
How to treat the pain! Non steroidal anti-inflammatories (NSAID)s: can trigger a flare (Ibuprofen, Motrin, Aleve, Naprosyn, Mobic)! If must be used, consider COX-2 selective inhibition (celecoxib/celebrex)! Narcotics: Associated with increased rates of infection and death in outpatients with Crohn s disease, could cause a dilated colon! Acetaminophen (Tylenol) at certain doses, tramadol OK! Anti spasmodics (Levsin, Bentyl)
Take Home Points! Stay in communication with your provider to formulate a treatment plan that is best for you! Stick to the plan, or discuss changes with your provider! There are always treatment options; there is always hope
Thank you! Questions?