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Treatment of Inflammatory Bowel Disease

A. Asher Kornbluth, MD

Introduction

Inflammatory bowel disease (IBD) consists mainly of ulcerative colitis (UC) and Crohn's disease (CD). Although no cure for IBD (other than surgery for advanced UC) exists at present, effective treatments are available. Active participation of patients in the treatment of their IBD and open communication with their physician is critical for a successful outcome. This newsletter will review the treatment options available and some steps you as the patient can take to help maintain a healthy lifestyle.

At times patients may be reluctant to discuss their symptoms with their physician. For example, it can be embarrassing to discuss urgency or incontinence when one doesn't make it to the bathroom in time. Yet these are precisely the types of things your physician needs to know to make sure you are receiving comprehensive treatment for your condition. Frankness and honesty with your physician is essential to maintaining your health as symptom free as possible.

It's important to recognize the early signs of a flare up and know when to call the doctor. Watching one's diet and knowing which foods and beverages to avoid can be valuable in preventing a flare up of IBD for some patients. The variety of medicines available and the plethora of Web sites recommending treatments can be beneficial but at the same time confusing. It's important to be familiar with the medications used to treat your disease and to discuss any questions you may have about them with your physician. It's also very important to tell your physician about everything you are taking including vitamins, herbs, and other supplements. Some of these can be helpful, but others may interfere with your medications. Always talk to your doctor before starting a new treatment, whether it is a prescribed medication or an over-the-counter supplement, vitamin, or other complementary approach, or before stopping any of the medications she or he has prescribed.

Signs of a Flare Up

Early recognition and action on symptoms may prevent a full-blown flare up. The first sign might be an unsettled stomach or slight lower abdominal discomfort. A low-grade fever that is not accompanied by signs of the flu or a cold can be an early warning sign of an impending flare. Another can be a generalized, persistent feeling of being run down and fatigued that is not attributable to anything in particular. You may notice an increase in the number of your daily trips to the bathroom or begin passing mucus and/or blood from your rectum. Pressure or tenderness in the lower abdomen and occasional bouts of diarrhea can also be signs. Your doctor may want you to make an appointment at the first sign of trouble. Others may want to help you plan a strategy of self-management and reserve office visits for more severe symptoms. In any case, it is important to promptly discuss with your physician what you should do when these symptoms occur.

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When to Call the Doctor

An occasional abdominal cramp, wisp of blood while wiping, or a few extra trips to the bathroom a day are normal aspects of IBD and do not usually warrant a call to the doctor. However, any significant or persistent change in symptoms should prompt a call. Unless your physician advises you otherwise, call to tell the staff your symptoms when you experience any of the following:

• Increase in diarrhea
• Abdominal pain
• Increase in bleeding
• Fever greater than 100°F
• Rectal pain
• Increase in cramping
• A tender area on the abdomen
• Symptoms in the eyes, skin, bones, and joints.
  
  
  
  For more information on these symptoms, you can read
  
  Volume 3 of this newsletter series,
  
  "The Clinical Course of IBD" by Maria T. Abreu, MD.

Call the doctor immediately if you experience any of the following:

• Significant loss of blood in a brief period
• Heavy diarrhea that leads to signs of dehydration,
  
  such as increased thirst, chapped lips, lethargy, dizziness,
  
  dry mouth and sticky saliva, reduced urine output,
  
  and dark yellow urine
• Dizziness or fainting
• Intense abdominal pain that makes moving difficult
• Wavelike abdominal pain associated with eating
• Protracted nausea and vomiting
• Sudden fever over 102°F

It is easier to prevent a relapse than it is to treat a recurrence of IBD. While it's human nature to want to taper or discontinue a drug when one is feeling well, in IBD this often doesn't work. Staying on medication may help prevent a relapse or the need for even stronger medication. You can read more about the importance of staying on your medication in Volume 1 of this newsletter series, "Staying on Medication - Your Health Depends On It" by Stephen B. Hanauer, MD.

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Medications for IBD

Because there's no cure for IBD at present, the role of medication is to control the symptoms. Some medications may be protective, that is, they may help prevent the progression of the disease. Some research actually indicates that patients who take their medication regularly as prescribed, in general, go longer between relapses than those who do not.

The medication your physician prescribes is based on the location of your disease or inflammation, and the severity, type, and frequency of symptoms you experience. The table below explains the uses of some of the medications most commonly used to treat IBD either alone or in combination, including: oral 5-aminosalicylates (5-ASAs), such as Colazal®, Asacol®, Pentasa®, Dipentum®, and Azulfidine®; rectal 5-ASAs, such as Rowasa® and Canasa®; antibiotics; steroids; and immunomodulators. Many of the medications used to treat IBD were initially developed to treat other diseases that have symptoms in common with IBD. With the exception of 5-ASAs, which do have Food and Drug Administration (FDA) approval for UC, most of these medications have not been evaluated by the FDA specifically for IBD.

Steroids

The oldest class of drugs used to treat IBD is steroids. These steroids are corticosteroids and are very different than the anabolic steroids that you hear about athletes abusing. They have been in use for almost 50 years and act quickly and powerfully to stop an IBD attack in most people. They are ineffective as medications for preventing an attack. Steroids are produced naturally by the human body in the adrenal glands, but when an IBD attack occurs the body usually needs more than it can produce by itself to bring the attack under control. Thus synthetic steroids have been created that are nearly identical to those the body produces. You may hear them called by different names such as budesonide, corticosteroids, glucocorticosteriods, hydrocortisone, methylprednisone, prednisolone, prednisone, and so on. The formulations differ somewhat and individual circumstances may dictate which one is selected. The steroids act to control the inflammatory process.

Steroids for IBD can be administered in foams, creams, and enemas that are inserted into the rectum, in pills taken by mouth, and in liquids administered intravenously. Steroids should never be discontinued abruptly because the adrenal gland may not function properly and patients may show symptoms of insufficient adrenal gland function and blood pressure could drop dangerously low.

Steroids are a very powerful tool to treat IBD. However, they act systemically and can create many serious unwanted effects throughout the body; for example, they can cause patients to be more susceptible to infections. Virtually every organ system in the body can be adversely affected by steroids. Thus they should be used as infrequently as possible and for as short a time period as possible.

Antibiotics

Bacteria may play a role in IBD, particularly in Crohn's disease, which is not fully understood. (For more information on what causes IBD and the role of bacteria, you can read Volume 2 of this newsletter series, "What Causes Inflammatory Bowel Disease" by Daniel H. Present, MD.) Thus the role of antibiotics in the treatment of IBD is somewhat controversial. They have an important role in treating complications of surgery for IBD, perianal disease, and a rare condition called toxic megacolon. Whether they are effective in altering the long-term course of the IBD itself is less clear. They appear to be more helpful in mild-to-moderate CD than UC.

Immunomodulators

Immunomodulators are a class of medications that are used to suppress the immune system. They are widely used in transplant surgery to prevent the rejection of donor organs, to treat leukemia and cancer, and to control inflammation in chronic conditions, such as rheumatoid arthritis. They are used in IBD to suppress the immune system's attack on the intestinal tract and control inflammation.

Immunomodulators can be used to treat both acute attacks and as drugs to maintain remission. Response to these medications is highly individual so physicians will usually start patients on a low daily dose based on the patient's weight and increase the dose every 10-14 days depending on response and side effects. It takes several weeks to months for these medications to achieve their full effect so they are usually prescribed in combination with faster acting drugs. These medications are given either by injection, intravenously, or sometimes as oral formulations and need to be closely monitored. Patients who take these medications will have their blood tested regularly to ensure that benefit is being gained without harming their red and white cell blood counts or their liver.

Biologics

Biologics are the newest class of drugs used in the treatment of IBD. Infliximab (Remicade®) is the only biologic with FDA approval at this time and was specifically developed to treat CD. Remicade is administered intravenously at a hospital or an infusion center, which may be in your local physician's office. Doses are usually given at week zero, two weeks later, and then six weeks later. It can be administered every eight weeks to maintain remission. Remicade works to prevent inflammation by inhibiting a potent inflammatory substance known as tumor necrosis factor.

Probiotics

Probiotics are considered the "friendly", "beneficial", or "good" bacteria that are natural inhabitants of the healthy intestinal tract. They are often taken to maintain a healthy balance of intestinal flora. These are currently being investigated for their potential benefit in the treatment of IBD. So far, clinical trials have had mixed results.

All of these medications play an essential role in the treatment of IBD but their use is highly specific to the individual patient. IBD is not a condition where "one size fits all." You and your doctor will determine what's best for you.

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Diet

Diet will be covered in greater depth in an upcoming newsletter, but you should be sure to eat a well-balanced diet to make up for nutrient losses as a result of your IBD symptoms. Avoid foods that bother you. These can be highly individual. Many people have difficulty with spicy foods and dairy products. Take a balanced vitamin supplement, adequate calcium, and vitamin D, and make sure your diet is adequate in folate. If it isn't, take a folate supplement as well. Some patients may require vitamin B12 supplements administered as a nasal spray or periodic injection.

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Herbs and Health Food Supplements

We have very little scientific information about herbs and other food supplements to tell you whether they can be of help in treating IBD or managing its symptoms. The National Institute of Health has created a complementary medicine division in recent years and our knowledge of this arena is beginning to improve.

The biggest concern about herbs and other health food supplements is that they are totally unregulated. "Natural" is a virtually meaningless term. For example, cyanide occurs naturally in some plants, but no one would ever recommend that someone take it for inflammatory bowel disease. Because herbs and supplements are unregulated, we have no way of knowing what is actually in them or if they provide any of the benefits they claim. Multiple tests of many of the products have shown wide differences in the amount of the active ingredient despite what the container claims and some have had no active ingredients at all.

Herbs and other food supplements may also adversely interact with your prescribed medicines. So it is very important that you tell your physician about any of these products that you are taking and that you ask your physician before you start anything new. A few Web sites exist that can provide you with reliable information about these products.*

www.iherb.com makes The Natural Pharmacist (TNP) available. TNP is prepared by physicians and pharmacists at Healthgate Data Corporation, an organization that provides information to hospitals, insurers, and pharmaceutical companies.

www.cfsan.fda.gov/%7Edms/ds-warn.html is a Web site of the FDA that tells consumers what products it has found to be dangerous.

http://dietary-supplements.info.nih.gov/showpage.aspx?pageid=90 is the Web page of the National Institutes of Health's Office of Dietary Supplements. It provides links to fact sheets on numerous supplements.

www.mskcc.org/mskcc/html/11570.cfm is the Web site of the Memorial Sloan-Kettering's Integrative Medicine Service. It provides information on more than 100 supplements and their potential interactions with some drugs and evaluates alternative cancer therapies.

All medications have potential side effects. Some of these are desirable while others can cause serious harm. A future newsletter will discuss side effects in detail. It's important to keep your physician informed about how your body responds to the medications you take.

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Conclusion

In the past, few treatment options existed for the treatment of ulcerative colitis and Crohn's disease. People afflicted with these diseases often faced serious disability. Today we have a strong arsenal of good medications to battle IBD. These medications aren't perfect, but now deaths from these diseases are very rare and most people with IBD lead normal, active lifestyles. Physician scientists, pharmaceutical researchers, and others continue to pursue new and improved medications to make the treatment of IBD even better. Patients can contribute a lot to their successful treatment through open communication with their physicians about their symptoms, carefully taking their medicines as prescribed, and leading a healthy lifestyle.

This information has been reviewed and approved by CCFA's National Scientific Advisory Committee.

The next newsletter in this series by Asher Kornbluth, MD, will discuss the treatment options for inflammatory bowel disease. To sign up for future newsletters click here.

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