Transcript Inflammatory Bowel Disease

Inflammatory Bowel Disease
Katie Benner
VTS 2
Crohns & UC
• Complex disorders & wide variation in
clinical practice
• Chronic idiopathic inflammaotry intestinal
conditions
• Patients may find symptoms embarassing
• May result in loss of education/
employment difficulties
• Growth failure, psych probs, sexual
development probs
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Often presents young
Lifelong disease
Disproportionately high impact on society
Hospital serving 300,000 sees 45-90 new
cases per annum
• Small increase in mortality for both
Approach to care
• High level of training
• Central hospitals supporting DGHs
• Rapid access to clinic appts for new/
known pts
• Provide counselling and educational
material
• Access to private toilet facilities
• Multi disciplinary team
Patient’s experience
• See pts as individuals not as the disease
• Views on “right” and “wrong” life
approaches to be avoided
• Respect pts expertise
• Sympathy, compassion & interest
Diagnosis
• Symptoms often dismissed as “stress
related”
• Rapid access to hospital ixs
• Rapid referral to gastroenterologist
specialising in IBD
History
• Stool frequency/ consistency/ urgency/
rectal bleeding/ tenesmus/ abdo pain/
malaise/ fever/ weight loss
• Extraintestinal- joint/ eye/ cutaneous
• Travel/ smoking/ FH/ medication
Examination
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General wellbeing
Pulse, BP and temp
Signs anaemia
Fluid depletion, weight loss
Abdo pain/ distension/ palp. masses
Perineal exam
Investigations
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FBC/ U&E/ LFT/ ESR/ CRP
Micro testing for infectious diarrhoea
Additional tests for abroad travellers
Abdominal imaging r/o toxic megacolon (in
hosp)
• Felxi sigi/ colonoscopy (disease extent/
severity)
• Histopathology
Drugs used
• Rapidly evolving field, likely to change
drastically in next 10 years
• Usually started in secondary care, but
useful to know what they do, how to
monitor, what side effects to watch out for
Aminosalicylates
• E.g. Mesalazine/ “Pentasa”
• Oral tablets/ sachets/ suspension/ liquid/
foam enemas/ suppositories
• act on epithelial cells by a variety of
mechanisms to moderate the release of
lipid mediators, cytokines, and reactive
oxygen species
• Better tolerability than sulfasalazine
• Higher doses to induce remission
Aminosalicylates cont…
• Mesalazine intolerance in 15%
• Diarrhoea/ headache/ nausea/ rash
Corticosteroids
• Oral/ IV/ topical/ suppositories/ foam
enemas
• Potent anti-inflammatories for moderate to
severe relapses of CD or UC
• Combination of oral & rectal better
• 40mg pred optimal for outpatient
management
• Too rapid a reduction assd with relapse
Corticosteroids cont..
• Decision to use must be weighed up
against risks
• Should be weaned slowly e.g. at 5mg/
week
• 50% pts report no adverse effects
• Cosmetic e.g. moon face, sleep &
psychiatric
Thiopurines
• E.g. “azathioprine”
• mechanism of immunomodulation is by
inducing T cell apoptosis by modulating
cell signalling
• Note potential hepatotoxicity
• Need LFT monitoring (organised thru
pharmacy)
• Use in active disease and maintaining
remission
Thiopurines cont…
• Role is steroid sparing
• Consider in pts needing 2 or more courses
steroids in a year
• (This is also when they need secondary
care input)
• thiopurine methyl transferase (TPMT)
must be tested 1st
• If TPMT deficient ^ risk myelotoxicity
Thiopurines cont…
• 20% intolerance
• Flu like symptoms 2-3 weeks after started
& resolve once drug withdrawn
• Profound leucopenia in 3%
• Hepatoxicity and pancreatitis in <5%
• Can be continued in pregnancy if IBD felt
to be refractory
Methotrexate
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Unlicensed in IBD
Oral/ IM/ SC
Mechanism unclear
Useful in inducing remission
25mg/week (15mg/week in RA)
Measure FBC and LFT before starting and
monthly thereafter
Methotrexate cont…
• Nausea/ vomiting/ diarrhoea/ stomatitis
• Limited by co-rx folic acid
• Pneumonitis occurs in 2-3%
Ciclosporin
• Inhibitor of calcineurin, preventing clonal
expansion of T-cell subsets
• Rapid onset of action
• Used in mx severe UC
• Can be used as IV salvage therapy in those
heading for colectomy
• Measurement of blood pressure, full blood
count, renal function, and CsA concentration at
0, 1, and 2 weeks, then monthly
Ciclosporin cont…
• Minor side effects in 31-51%
• Tremor/ paraesthesia/ malaise/ headache,
abnormal LFTs/ gingival hyperplasia/
hirsutism
• Major s/es in up to 17%
• Renal impairment/ infections/ neurotoxicity
• May require pneumocystis cariinei jab
Infliximab
• Chimeric anti-TNF monoclonal antibody
with potent anti-inflammatory effects
• Needs to be done in secondary care
• Need maintenance doses, intitially after 2
weeks, 8+ weekly thereafter
• Need pre- infliximab virology checks (with
pt consent), CXR and EBV in men under
30
• Further doses given on PIU in Barnsley
Infliximab cont…
• Use with immunomodulator as increase
interval between doses
• Rarely infusion reactions
• Delayed reactions of joint pain/ myalgia/
fever
• Theoretical risk of lymphoproliferative
disorders
Surgery
• Disease not responding to intensive
medical therapy
• Manage between surgeon and
gastroenterologist
• Pre-operative conselling and involvement
of stoma nurse specialist
• Subtotal colectomy leaving long rectal
stump
Surveillance for colonic carcinoma
• UC pts should get repeat colonscopy in 810 years
• Extensive colitis (opting for surveillance) 3yearly in teens, 2-yearly in 20s and yearly
in 30s
• Pts with PSC have higher risk of cancer
and should have annual colonscopies
Pt information
• NACC: The National Association for Colitis and
Crohn’s disease, 4 Beaumont House, Sutton
Road, St Albans, Herts AL1 5HH, UK.
Information Line: 01727 844296; website:
www.nacc.org.uk
• CCFA: The Crohn’s and Colitis Foundation of
America; website: www.ccfa.org
• CORE/DDF: Digestive Diseases Foundation, PO
Box 251, Edgware, Middlesex, HA8 6HG, UK.
Who to contact?
• Debbie (IBD specialist nurse) on bleep
591 or 01226 436371
• Specific IBD advice line 2-3pm
References
• British Society of Gastroenterology
• Guidelines for the management of
inflammatory bowel disease in adults
• Gut 2004
Thank you
• Any questions?