Presentation on theme: "Management of Inflammatory bowel disease 8/12/10."— Presentation transcript:
Management of Inflammatory bowel disease 8/12/10
Management of Crohn’s disease Stop smoking Treat diarrhoea symptomatically with codeine phos or loperamide unless due to active disease Cholestyramine 4g 1-3 times daily reduces diarrhoea due to terminal ileal disease or resection NSAIDs precipitate relapse - avoid
Cholestyramine Treatment-resistant diarrhoea in Crohn's disease may be due to bile salt malabsorption. Cholestyramine may be helpful. Care must be taken to avoid taking cholestyramine at the same time as other medication, the absorption of which may be impaired.
Management of Crohn’ s Disease 5-ASA derivative less effective in Crohn’s than for UC Ineffective for maintenance at less than 2g daily and flare ups should be treated with 4 g daily
Mesalazine 5-aminosalycyclic acid. It is used as an alternative to sulphasalazine patients who do not tolerate sulphasalazine it has been shown that 5-ASA analogues are as effective as sulphasalazine in preventing relapses of ulcerative colitis some consultants recommend mesalazine rather than suphasalazine to be used men with inflammatory bowel disease who wish to start a family (sulphalazine causes reversible infertility)
Steroids Steroids are added if active disease is unresponsive to mesalazine Review frequently Taper over 8/52 Rapid withdrawal increases risk of relapse Steroids are associated with increased risk of severe sepsis and mortality in Crohn’s
Management of Crohn’s disease Alternatives are increasingly sought and maintenance for longer than 3/12 avoided Elemental or polymeric diets for 4-6 weeks can be a useful adjunct – take consultant advice
Management of Crohn’s disease Other treatments – Metronidazole Azathioprine Methotrexate Infliximab Surgery After ileal resection check B12 levels annually.
Infliximab anti-TNF monoclonal antibody primarily designed for the treatment of rheumatoid arthritis It is given by intravenous infusion at 0,2 and 6 weeks then every 8 weeks thereafter induces endoscopic and clinical remission in the 60% of patients with Crohn's disease that is unresponsive to azathioprine and steroids major limitations to the use of infliximab include the intravenous route of administration of the drug and expense
Management of UC 5-ASA derivative mesalazine 1-2 g daily as maintenance Dose can be increased to 2-4g daily in primary care to treat flare-ups Topical 5-ASA derivatives are a useful adjunct for rectal disease Proximal constipation treated with stool bulking agents or laxatives NSAIDs can precipitate relapse - avoid
Management of UC Steroids (40mg daily + rectal) are added if prompt response needed or mesalazine unsuccessful Either GP or specialist Review frequently and taper over 8/52 Consider osteoporosis prevention Cyclosporin or infliximab (anti-TNF antibody) under specialist care
Management of UC Azathioprine 3 rd line agent Specialist initiation Used for 10% of UC sufferers intolerant to 5-ASA derivatives Added for recurrent attacks, 2 or more courses of steroids per year, relapse as steroid tapered, relapses within 6 weeks of stopping steroids
Management of UC Monitor FBC and LFT on azathioprine Surgery – last resort
When to refer? For patients with diagnosis of IBD, refer back if continuing disabling symptoms despite treatment Worsening or new symptoms but not requiring admission Urgency of referral depends on clinical state of patient
GI Malignancy Patients with IBD have increased risk of GI cancer Crohn’s – large and small bowel cancer. 5% develop tumour within 10 years of diagnosis 5% of patients with UC develop colonic cancer Tends to develop at a relatively young age – peak incidence 48yrs
Other Considerations Psychosocial Work Embarassment Relationships Body image Side effects of medication Fertility
Long Term support in Primary Care MDT approach National Association for Colitis and Crohn’s Disease www.nacc.org.uk www.nacc.org.uk References – InnovAiT September 2008
Ulcerative colitis: flares Flares of ulcerative colitis are usually classified as either mild, moderate or severe: Mild: Fewer than four stools daily, with or without blood Fewer than four stools daily, with or without blood No systemic disturbance No systemic disturbance Normal erythrocyte sedimentation rate and C- reactive protein values Normal erythrocyte sedimentation rate and C- reactive protein values
Ulcerative colitis: flares Moderate Four to six stools a day, with minimal systemic disturbance Four to six stools a day, with minimal systemic disturbance
Ulcerative colitis: flares Severe More than six stools a day, containing blood More than six stools a day, containing blood Evidence of systemic disturbance, e.g. Evidence of systemic disturbance, e.g. Fever Fever Tachycardia Tachycardia Abdominal tenderness, distension or reduced bowel sounds Abdominal tenderness, distension or reduced bowel sounds Anaemia Anaemia Hypoalbuminaemia Hypoalbuminaemia Patients with evidence of severe disease should be admitted to hospital.