by David T. Rubin, MD
David T. Rubin, MD, is Associate Professor of Medicine, Department of Medicine, and Program Director for the Fellowship in Gastroenterology, Hepatology and Nutrition and Co-Director of
Inflammatory Bowel Disease Center at the University of Chicago Medical Center in Chicago, Illinois. His clinical practice is based at the Reva and David Logan Center for Inflammatory Bowel Disease.
Dr Rubin has been an invited reviewer for such journals as the Gastroenterology, American Journal of Gastroenterology, Clinical Gastroenterology/Hepatology, and Inflammatory Bowel Disease. An avid
researcher, Dr Rubin’s interests include colon cancer screening and prevention, inflammatory bowel disease (IBD), teaching medicine, and clinical medical ethics. He is currently the principal
investigator for several research projects and clinical trials. Dr Rubin has contributed numerous peer-reviewed publications, book chapters, review articles and abstracts to the medical literature.
Table of Contents
Introduction
When inflammatory bowel disease (IBD) is active, it can be accompanied by an urgent need to use the bathroom.
This is due to a combination of diarrhea or bleeding, as well as the inability of the rectum to stretch or store waste as effectively as it should.
When this occurs, there is cramping and pain with the urgency to evacuate. It is a terrible feeling and the loss of control is one of the hardest things about IBD.
Although the goal for all our patients is stable remission, it is important to have strategies to cope with your condition when it is active, so you are not socially isolated.
When the disease is active or when you feel that your control is unpredictable, the thought of leaving your home becomes a daunting prospect,
in part because it may be a challenge to find a restroom quickly when you are out and about.
In addition, although there are bathrooms in almost every place of business, they are often for employee use only and not available to the public.
The good news is that a number of states now have passed Restroom Access Acts -- legislation that helps make venturing out from home a little easier.
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What is a “Restroom Access Act?”
A Restroom Access Act is a law that requires businesses to make employee-only restrooms available to people with IBD and other chronic medical conditions, as well as pregnancy.
The first Restroom Access Act, which is commonly known as “Ally’s Law,” was passed in Illinois in 2005, thanks to the work of one of my patients, Allyson Bain.
As a teen with active Crohn’s disease, Ally experienced the indignity of being denied access to a store’s employee restroom, and she had an accident at the store.
Click here to read an interview with Ally.
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Which other states have passed a Restroom Access Act?
In addition to Illinois, 11 other states – Minnesota, Texas, Kentucky, Tennessee, Colorado, Ohio, Michigan, Washington, Oregon, Wisconsin, and Connecticut
-- have passed Restroom Access Acts.
Has your state passed a Restroom Access Act? Click here to find out.
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How do I know if a Restroom Access Act is in the works in my state?
The Crohn’s and Colitis Foundation of America (CCFA) monitors advocacy issues related to IBD, so a visit to their website is very helpful. (click here to find your local chapter).
You can also try checking the website for your state legislature (click here to find the website, by selecting the name of your state and “homepage” from the list of content areas).
The websites for many state legislatures allow you to search for bills by keyword (eg, “restroom”).
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Restroom Access Act legislation has been introduced in my state, what can I do to help it pass?
Contact the senator and/or representative who sponsored the legislation and ask how you can help.
For example you might volunteer to tell your story during committee testimony and rally others to do the same.
Also contact your own representative to discuss the importance of voting for the bill and to share your own personal experiences around the restroom access issue.
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Restroom Access Act legislation has not yet been introduced in my state, what can I do to get the ball rolling?
Arrange to meet with your state representative and senator during their office hours to share your story and the importance of a Restroom Access Act.
Describe how Restroom Access Act legislation has been passed in other states and provide samples of the text (see map below).
Follow up with a letter restating your case and thanking your representative for taking the time to meet with you.
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My state does not yet have a Restroom Access Act. What can I do when I’m away from home and need to use a restroom quickly?
When your disease is active, it’s wise to always know the locations of the closest public restrooms . . . before your need becomes urgent.
Believe it or not, there are websites that you can use to find public toilets (www.sitorsquat.com,
www.thebathroomdiaries.com, and www.mizpee.com/web).
Some of these sites also provide applications that you can access from your cell phone.
If you locate a bathroom, but find there’s a line, politely negotiate your way to the front. Chances are good that folks will understand.
If you are unable to quickly find a public restroom, don’t be afraid to ask to use a bathroom that appears to be only for employees or customers.
Politely explain your situation as firmly and succinctly as possible. Keep an “I Can’t Wait” or a “Medical Alert Restroom Access” card in your wallet and show it to a store employee if necessary.
The “I Can’t Wait” card is a benefit of CCFA membership (www.ccfa.org),
and you can order the “Medical Alert Restroom Access” card from the Foundation for Clinical Research in IBD (www.myibd.org/RestroomMedAlert/index.php).
Just in case, keep an “emergency kit” in your car. Think about including things like an extra change of underwear in a plastic bag, a towel, medicated wipes, a shirt or jacket that you can tie around your waist, and an extra pair of pants.
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Summary
Ideally, your IBD is under excellent control, and you don’t need to worry about uncontrollable symptoms.
You can maximize your control by working with your healthcare team and communicating your condition to them so that your therapy will be adjusted.
Nonetheless, flares can occur suddenly and symptoms can be unpredictable and embarrassing.
It is important to know that there is increasing awareness of the social challenges that arise with IBD and that there are laws to support patients in 12 states.
If your state hasn’t yet passed a similar law, you, like Ally, can make a difference!
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Interview with Ally Bain
Ally Bain, 20, a college junior, has Crohn’s disease. She is an aspiring writer, a political activist, and an advocate for inflammatory bowel disease (IBD) awareness.
Through her belief that one voice can make a difference, she helped create “Ally’s Law” and works to break the silence and stigma about IBD and encourage a culture of empowerment for those who suffer from the disease.
Photo by Jim Summaria
Question: How did you find the courage to go public about your condition when you were just 15?
AB: What made me bold was my upbringing. My parents have been wonderful role models.
They always told my brother and me to take action when we believe in something.
My mom, especially, is very assertive, and she doesn’t think that anyone is too powerful or too big to be challenged.
She always says that if someone says no, don’t give up, because they may eventually say yes.
In addition to teaching me to be assertive, my parents also kept me grounded.
The work I’ve been doing is for everyone, not just for me.
Another factor was that my younger brother Trevor had epilepsy, which has since been cured.
Helping to care for him made me grow up quickly and realize how fragile life can be, so I’ve probably always seemed older than my age.
Then I was diagnosed at 11, before I was in the sixth grade, and being ill also made me grow up more quickly than my peers.
Question: What led up to the work you did to get “Ally’s Law” passed?
AB: When I was in the eighth grade I went to the Illinois state capital in Springfield just months before the incident at Old Navy occurred, where I was denied access to a restroom and had an accident.
On that field trip it was so powerful to see how the political process works. We met with Kathy Ryg, then a state representative, who had distributed a booklet of contact information for state legislators.
After the Old Navy incident, I was crying while walking back to the car, and my mom said: “Let’s work to make sure that this never happens to you or anyone else again.”
So I found Kathy Ryg’s information in that booklet and called her. I told her the story about what had happened to me, and I told her that it should never happen to anyone again.
While Kathy Ryg worked on the legislative front, my dad suggested that my mom and I contact the media. The issue just grew from there. I was impressed with how many people got involved.
Question: What was it like for you when the law was passed in August 2005?
AB: It was surreal when it passed, and it has been one of the best experiences of my life. At the time I had gone through some complications with my Crohn’s disease, and I was having some problems with friends.
After the Illinois governor signed the legislation into law, I felt so empowered. I also realized how much I enjoyed being active politically and raising awareness about IBD.
Question: Do you have any plans to get this law passed elsewhere?
AB: I’m working to get the Restroom Access legislation passed on a federal level.
It’s very different from getting a law passed on a state level, and it’s much more difficult.
But I fight harder when others might get discouraged. Illinois Representative Carol Sente’s office and staff have been a great help to me.
Question: What is your current state of health?
AB: I’ve been feeling great for the past 4 or 5 years. I’m in remission, thanks to Dr Rubin at the University of Chicago.
I was at my sickest when I was 14. Dr Rubin promised remission for me in the next 6 months, and he kept his promise.
Since my surgeries, I’ve been feeling very healthy. I’ve also learned that people with Crohn’s disease should expect to be well and seek proactive care,
which, when provided at the right time, can help to avoid surgeries later.
Question: What are you studying in college?
AB: I am a student at Lake Forest College just outside Chicago, and I plan to major in communications and minor in political science.
Question: Besides college, what occupies your time these days?
AB: I have a summer internship with United Ostomy Associations of America, where I’m working on social media.
I also volunteer at a health center, putting together programs and events on nutrition and stress.
Besides continuing my work to promote federal legislation for restroom access, I’ve started writing a memoir detailing the origins of “Ally’s Law” and what it’s like to live with a chronic illness at a young age.
The title of the book is I Can’t Wait. It’s been nice to finally take the time to look back and reflect on my illness.
I’m also a member of Crohn’s and Colitis Foundation of America (CCFA) National Youth Leadership Council, which is a young adult leadership networking and advocates’ group.
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Important Safety Information about AZASAN
WARNING: Chronic immunosuppression with this purine antimetabolite increases risk of
malignancy in humans. Reports of malignancy include post-transplant lymphoma and
hepatosplenic T-cell lymphoma (HSTCL) in patients with inflammatory bowel disease. Physicians
using this drug should be very familiar with this risk as well as with the mutagenic potential to
both men and women and with possible hematologic toxicities. Physicians should inform patients
of the risk of malignancy with AZASAN. See WARNINGS.
AZASAN®
(azathioprine tablets) 75/100 mg is indicated as an adjunct for the prevention of rejection in
renal homotransplantations, and also for the management of active rheumatoid arthritis to reduce
signs and symptoms. Patients are at increased risk of developing lymphoma and other malignancies,
particularly of the skin. Exposure to sunlight and ultraviolet light should be limited by wearing protective
clothing and a high SPF sunscreen. Patients should have complete blood count (CBC), including platelet
counts periodically during treatment. TPMT testing should be conducted to identify with absent or
reduced TPMT activity. The most commonly reported side effects associated with AZASAN therapy are
leukopenia and/or thrombocytopenia, secondary infections, neoplasia, nausea, vomiting, diarrhea,
fever, myalgias, skin rashes, and hepatotoxicity. AZASAN therapy should be given cautiously when used
concomitantly with allopurinol, ACE inhibitors, and other agents affecting myelopoiesis. Patients with
rheumatoid arthritis previously treated with alkylating agents (cyclophosphamide, chlorambucil,
melphalan, or others) may have a prohibitive risk of malignancy if treated with AZASAN. AZASAN is
contraindicated in pregnant and lactating women and in patients who have shown hypersensitivity to
this product.
Consult with your physician to see if this product is right for you.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch/ or call 1-800-FDA-1088.
For product information, adverse event reports, and product complaint reports, please contact:
Salix Product Information Call Center
Phone: 1-800-508-0024
Fax: 1-510-595-8183
Email: salix@medcomsol.com
Please see complete Prescribing Information for AZASAN, including BOXED WARNING.
Indication for METOZOLV ODT
METOZOLV® ODT is indicated for short-term (4 to 12 weeks) therapy for adults with symptomatic, documented gastroesophageal reflux disease that fails to respond to conventional therapy (refractory GERD) and for the relief of symptoms associated with acute and recurrent diabetic gastroparesis (gastric stasis) in adults.
Important Safety Information about METOZOLV ODT
WARNING: TARDIVE DYSKINESIA
See full prescribing information for complete boxed warning.
Treatment with metoclopramide can cause tardive dyskinesia, a serious movement disorder that is
often irreversible. The risk of developing tardive dyskinesia increases with the duration of
treatment and the total cumulative dose.
Metoclopramide therapy should be discontinued in patients who develop signs or symptoms of
tardive dyskinesia. There is no known treatment for tardive dyskinesia. In some patients, symptoms may lessen or resolve after metoclopramide treatment is stopped.
Treatment with metoclopramide for longer than 12 weeks should be avoided in all but rare cases
where therapeutic benefit is thought to outweigh the risk of developing tardive dyskinesia.
METOZOLV® ODT
(metoclopramide HCl) orally disintegrating tablet therapy should not exceed 12 weeks in duration and is recommended for adults only (the safety and effectiveness in pediatric patients have not been established).
METOZOLV ODT is contraindicated in patients with intestinal obstruction, hemorrhage, or perforation;
pheochromocytoma; known sensitivity or intolerance to metoclopramide; epilepsy; or are receiving
concomitant medications with extrapyramidal reactions.
Extrapyramidal symptoms (EPS), manifested primarily as acute dystonic reactions, occur in
approximately 1 in 500 patients treated with the usual adult dosages of 30 to 40 mg/day of
metoclopramide. These usually are seen during the first 24 to 48 hours of treatment with
metoclopramide, occur more frequently in pediatric patients and adult patients less than 30 years of
age, and are even more frequent at higher doses.
Drug-induced Parkinsonism can occur during metoclopramide therapy, more commonly within the first
6 months after beginning treatment, but also after longer periods. Patients with a history of Parkinson’s
disease should be given metoclopramide cautiously, if at all, since such patients can experience
exacerbation of Parkinsonian symptoms when taking metoclopramide.
There have been rare reports of an uncommon but potentially fatal symptom complex sometimes
referred to as Neuroleptic Malignant Syndrome (NMS) associated with metoclopramide. Clinical
manifestations of NMS include hyperthermia, muscle rigidity, altered consciousness, and evidence of
autonomic instability. The management of NMS should include immediate discontinuation of
metoclopramide and other drugs not essential to concurrent therapy.
Depression associated with metoclopramide use has occurred in patients with and without a history of
depression. For those patients with a prior history of depression, metoclopramide should only be given
if the expected benefits outweigh the potential risks.
In one study in hypertensive patients, intravenously administered metoclopramide was shown to
release catecholamines; hence, caution should be exercised when metoclopramide is used in patients
with hypertension. Any rapid rise in blood pressure associated with METOZOLV ODT use should result in
immediate cessation of metoclopramide use in those patients.
Since metoclopramide produces a transient increase in plasma aldosterone, patients with cirrhosis or
congestive heart failure may be at risk of developing fluid retention and volume overload. If these side
effects occur at any time in any patients during metoclopramide therapy, the drug should be discontinued.
Patients may experience withdrawal symptoms after stopping METOZOLV ODT that could include
dizziness, nervousness, and/or headaches.
METOZOLV ODT interacts with anticholinergics, narcotic analgesics, monoamine oxidase inhibitors,
insulin, antidepressants, antipsychotics, and neuroleptics. METOZOLV ODT may alter drug absorption.
Elderly patients may be more sensitive to adverse reactions such as sedation and drug-induced movement disorders. In patients with impaired renal function, initial dosing may need to be reduced and titrated.
In clinical studies, the most frequently reported adverse events (≥2% occurrence) for METOZOLV ODT were headache, nausea, fatigue, somnolence, and vomiting.
Please see complete Prescribing Information for METOZOLV ODT, including BOXED WARNING.
Indication for OSMOPREP
OSMOPREP® (sodium phosphate monobasic monohydrate, USP, and sodium phosphate dibasic anhydrous, USP) Tablets are indicated for cleansing of the colon as a preparation for colonoscopy in adults 18 years of age or older.
Important Safety Information about OSMOPREP
WARNINGS
There have been rare, but serious reports of acute phosphate nephropathy in patients who received
oral sodium phosphate products for colon cleansing prior to colonoscopy. Some cases have resulted in
permanent impairment of renal function and some patients required long–term dialysis. While some
cases have occurred in patients without identifiable risk factors, patients at increased risk of acute
phosphate nephropathy may include those with increased age, hypovolemia, increased bowel transit
time (such as bowel obstruction), active colitis, or baseline kidney disease, and those using medicines
that affect renal perfusion or function (such as diuretics, angiotensin converting enzyme [ACE]
inhibitors, angiotensin receptor blockers [ARBs], and possibly nonsteroidal anti–inflammatory drugs
[NSAIDs]).
It is important to use the dose and dosing regimen as recommended (PM/AM split dose).
OSMOPREP® (sodium phosphate monobasic monohydrate, USP, and sodium phosphate dibasic
anhydrous, USP) Tablets are contraindicated in patients with a biopsy-proven acute phosphate
nephropathy, gastrointestinal (GI) obstruction, gastric bypass or stapling surgery, bowel perforation,
toxic colitis, toxic megacolon, and known allergy or hypersensitivity to sodium phosphate salts or any
component of OSMOPREP.
Renal impairment may occur with OSMOPREP. Assess renal function before treatment and during
therapy. Use OSMOPREP with caution in patients with impaired renal function (creatinine clearance less
than 30mL/minute), patients with a history of acute phosphate nephropathy, known or suspected
electrolyte disturbances (such as dehydration), or people taking concomitant medications that may
affect electrolyte levels (such as diuretics). Patients with electrolyte abnormalities (such as
hypernatremia, hyperphosphatemia, hypokalemia, or hypocalcemia) should have their electrolytes
corrected before treatment with OSMOPREP Tablets.
Seizures due to electrolyte abnormalities can occur. OSMOPREP should be used with caution in patients
with a history of seizures or at higher risk of seizure [e.g. patients using concomitant medications that
lower the seizure threshold (such as tricyclic antidepressants), patients withdrawing from alcohol or
benzodiazepines, or patients with known or suspected hyponatremia].
Use caution in patients with higher risk of arrhythmias (e.g., patients with a history of cardiomyopathy,
prolonged QT, uncontrolled arrhythmias, or recent myocardial infarction).
Advise patients to hydrate adequately before, during, and after the use of OSMOPREP.
Use OSMOPREP with caution in patients with history of Inflammatory Bowel Disease. In patients with
suspected GI obstruction or perforation, rule out the diagnosis before administration of OSMOPREP.
Animal reproduction studies have not been performed. OSMOPREP should only be given to a pregnant
woman if clearly needed.
In clinical trials, the most commonly reported adverse reactions (reporting frequency >3%) were
abdominal bloating, abdominal pain, nausea, and vomiting.
Please see complete Prescribing Information for OSMOPREP, including BOXED WARNING.
The information contained on this page is intended for US patients, healthcare professionals, and pharmacists only.