Inflammatory Bowel Disease: Why Should I Take My Medications?

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(No Transcript)
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Inflammatory Bowel Disease Why Should I Take My
Medications?

• Sunanda V. Kane, MD, MSPH
• Associate Professor of Medicine
• Mayo Clinic College of Medicine
• Rochester, Minnesota

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The Spectrum of IBD
12 Million Americans

• CROHNS DISEASE
• Patchy inflammation
• Mouth to anus involvement
• Full-thickness inflammation
• Variable involvement
• Fistulas
• Strictures
• Extraintestinal manifestations

• ULCERATIVE COLITIS
• Continuous inflammation
• Colon only
• Superficial inflammation
• Variable involvement
• Risk of cancer
• Strictures (cancer)
• Extraintestinal manifestations

Indeterminate colitis1015
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Potential Causes of IBD
Immune System Abnormalities
Genetic Predisposition
Environmental Factors
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Environmental Triggers
IBD
NSAIDsnonsteroidal anti-inflammatory drugs.
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Diagnosing IBD

• Clinical history
• Physical examination
• Laboratory tests
• Endoscopy (gastroscopy/colonoscopy)
• Findings on X-ray films
• Tissue biopsy (pathology)

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Questions Frequently MissedDuring History-Taking

• Family history for second-degree relatives
• NSAID use
• Antibiotic use
• Recent/previous infections

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Clues in the Physical Examination

• Clues are present from head to toe
• Aphthous oral ulcers
• Pale conjunctiva, red eyes
• Skin rashes
• Abdominal mass
• Perianal abnormalities

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Ulcerative Colitis
Left-sided colitis
Proctitis
Pancolitis

• The small intestine is not involved

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Symptoms of Ulcerative Colitis

• Symptoms depend on extent and severity of
  inflammation
• Rectal bleeding and urgency to evacuate
• Diarrhea
• Abdominal cramping
• Extraintestinal (systemic) symptoms
• Joint pain/swelling
• Eye inflammation
• Skin lesions

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Common Symptoms of Crohns Disease

• Diarrhea
• Abdominal pain and tenderness
• Loss of appetite and weight loss
• Fever
• Fatigue
• Rectal bleeding and anal ulcers
• Stunted growth in children

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Laboratory Tests

• Routine laboratory tests are ordered first
• Complete blood count to rule out infection and
  anemia
• C-reactive protein to assess for active
  inflammation
• Chemistry panel for electrolytes and proteins
• Thyroid-stimulating hormone for weight loss
• Celiac testing of the physicians choice
• Stool studies
• Ova and parasite examinations, but yield may be
  low
• Clostridium difficile toxin
• White blood cell count, lactoferrin, and
  calprotectin

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Diagnostic Studies Small Bowel Series

• A long stricture in the terminal ileum (Kantors
  string sign)

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Endoscopy
Ulcerative colitis
Crohns disease
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Endoscopy
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Management Goals for IBD
Relievesymptoms
Address psychosocial issues
EstablishDiagnosis
Treat inflammation
Identify dysplasia and detect cancer
Treatcomplications
Improve daily functioning
Replenish nutritional deficits
Minimize treatment toxicity
Maintain remission
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Medical Therapies for IBD

• 5-aminosalicylic acid (5-ASA) agents
• Mesalamine
• Delayed release tablets, Lialda
• Delayed release tablets, Asacol
• Controlled-release capsules, Pentasa
• Rectal suspension (Rowasa enema)
• Rectal suppository (Canasa)
• Sulfasalazine (Azulfidine)
• Balsalazide (Colazal)
• Olsalazine (Dipentum)

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Medical Therapies for IBD

• Antibiotics
• Ciprofloxacin (Cipro)
• Metronidazole (Flagyl)
• Steroids
• Adrenocorticotropic hormone
• Budesonide
• Methylprednisolone (Medrol)
• Prednisone
• Hydrocortisone (Cortenema, Cortifoam)

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Medical Therapies for IBD

• Immunologic agents
• Azathioprine (Imuran, Azasan)
• 6-Mercaptopurine (Purinethol)
• Cyclosporine (Neoral)
• Methotrexate
• Biologic agents
• Infliximab (Remicade)
• Adalimumab (Humira)
• Natalizumab (Tysabri)

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• Drugs dont work in patients who dont take them.

- C. Everett Koop, MD Former US Surgeon
General
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Factors that Affect Adherence

• Adherence is taking medications over a long
  period of time
• Extent, duration, and severity of disease affect
  adherence
• People who are more likely to adhere to therapy
• Have more disease flare-ups
• Are more knowledgeable about their treatment
• Clear instructions and educational materials
  provided by healthcare professionals increases
  knowledge about
• Importance of treatment
• Risks of non-adherence

Hall A, et al. Gastrointestinal Nurs.
2006431-40. Lopez-Sanroman A, Bermejo F.
Aliment Pharmacol Ther. 200624(Suppl
3)45-49. Kane SV. Aliment Pharmacol Ther.
200623577-585.
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Risk Factors for Non-Adherence
Risk Factor Odds Ratio (95 CI)
Married 0.46 (0.39-0.57)
Recent procedure 0.96 (0.93-0.99)
Greater extent of disease 0.55 (0.22-1.3)
Male gender 2.1 (1.2-4.8)
Taking more than 4 medications 2.5 (1.4-5.7)
Kane SV, et al. Am J Gastroenterol.
2001962929-2932.
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National Quality Forum Report

• Goals
• Improve medication adherence by creating
  standards to change the way healthcare
  professionals interact with patients
• Develop standard performance measures that could
  be implemented in patient care settings to
  improve adherence
• Recommendations
• Adherence needs to be evaluated as a vital sign,
  every time a patient is seen by a physician or
  nurse
• Ask the questions Are you taking the medication,
  how are you taking it, and what is the dose?

Traynor K. Am J Health-Syst Pharm.
2005622440-2442.
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Significant Factors Associated with Risk of Not
Refilling 5-ASA at 3 Months
Patients More Likely to be Adherent
Rectal 5-ASA Glucocorticoid use
Copay (per 1 increase) Lower daily pill load
(per 1 pill decrease) Male gender Mail
order Psychiatric history
Patients Less Likely to be Adherent
3,574 UC patients with 5-ASA prescriptions
1,530 (42.8) patients did not refill at 3
months. ? 12 months prior to index date. Kane
S, et al. Gastroenterology. 2007132(4 Suppl
2)M1033.
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Adherence Decreases Risk of Relapse
100
Adherent
75
Patients Remaining in Remission,
50
Non-adherent
25
0
0
12
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Time (months)
36
40
36
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Adherent n
Non-adherent n
59
32
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From Kane S, et al. Am J Med.
200311439-43 with permission.
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Adherence Decreases Risk of Relapse

• Prospective study in patients with UC in
  remission and taking mesalamine found chance of
  remission was
• 89 in adherent patients
• 39 in non-adherent patients

Kane S, et al. Am J Med. 200311439-43.
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Non-Adherence is Associated with Recurrence
No Recurrence
Recurrence
Medication Refilled in Previous 6 Months,
Follow-up
From Kane S, et al. Am J Med. 200311439-43
with permission.
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Non-Adherence is Associated with Recurrence

• 82 of patients with recurrence had not taken
  their medication
• 34 of patients remaining in remission had not
  taken their medication

Kane S, et al. Am J Med. 200311439-43.
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Other Factors that Affect Adherence

• Adverse reactions to medications
• Need for many medications
• Effectiveness of treatment
• Convenience of treatment

Hall A, et al. Gastrointestinal Nurs.
2006431-40. Lopez-Sanroman A, Bermejo F.
Aliment Pharmacol Ther. 2006 24(Suppl
3)45-49. Kane SV. Aliment Pharmacol Ther.
200623577-585.
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To Increase Treatment Adherence

• Simplify the treatment regimen
• Continue taking the medications
• Find support for emotional and social issues

Hall A, et al. Gastrointestinal Nurs.
2006431-40. Lopez-Sanroman A, Bermejo F.
Aliment Pharmacol Ther. 200624(Suppl
3)45-49. Kane SV. Aliment Pharmacol Ther.
200623577-585.
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Patient-Centered Self-Management Training
Self-Guided Group Control Group P-Value
Time to treat relapses 14.8 h 49.6 h lt0.0001
Outpatient visits 0.9 2.9 lt0.0001
Time spent visiting a doctor 1 h 6.2 h lt0.0001

• Patients preferred guided self-management over
  traditional outpatient care
• Patient-centered self-management resulted in
• Earlier treatment of relapses
• Fewer hospital and primary care visits
• Less time spent during a visit with a doctor

Robinson A, et al. Lancet. 2001358976-981.
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Why Take Your Medications?

• Possible decreased risk of colorectal cancer
• Decreased risk of disease progression
• Increased chance of disease regression

Velayos FS, et al. Am J Gastroenterol.
20051001345-1353. Pica R, et al. Inflamm Bowel
Dis. 200410731-736. Picco MF, et al. Inflamm
Bowel Dis. 200612537-542.