Ten Pearls for Treating IBD

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Ten Pearls for Treating IBD

• Debra J. Helper MD
• Associate Professor Clinical Medicine
• Indiana University School of Medicine

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1

• Use the right drug for the right reason at the
  right dose
• Goals
• Achieve remission
• Maintain remission
• Discontinue steroids
• Delivery site
• Terminal ileum
• Left colon/rectum
• Optimum dosage

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2

• Wait long enough for desired effect
• 5ASA 6 weeks
• Azathioprine/6 MP 3 6 months
• Methotrexate 2 4 months
• Biologic agents 4 weeks

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3

• Use topical 5ASA agents for ulcerative colitis
  limited to the left side or rectum with or
  without oral 5ASA
• More efficacious than steroids
• Enemas reach splenic flexure suppositories treat
  the rectum
• Oral plus topical may be better than either alone
• Can be used for maintenance

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• For ulcerative colitis, 5ASA agents are basically
  equivalent
• Side effects may differ especially sulfasalazine
• Be aware of possibility they may worsen colitis
  (4)

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• Be aggressive about limiting steroids
• Taper at a reasonable rate (1mg/d or 10 mg every
  one to two weeks)
• Add a steroid sparing agent early1
• Azathioprine/6 mercaptopurine
• Methotrexate
• Biologic agent
• 1 www.lancet.com Vol 371660-667Feb 2008.

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• Respect, dont fear, immunosuppressants and
  biologic agents
• Consider riskbenefit alternative therapies
• Monitor closely
• PPD/CXray prior to biologics r/o abscess
• Hold if fever or infection
• Aggressively evaluate for atypical infection
• Be prepared to manage infusion reactions
• Women on Aza/6MP at higher risk for cervical CA

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• Surgery is not always bad
• Therapy of choice for symptomatic strictures
• Drain abscesses control perianal sepsis
• Total proctocolectomy with ileoanal pouch for
  refractory UC or dysplasia/cancer
• Total proctocolectomy with end-ileostomy for
  extensive Crohns colitis low recurrence rate if
  no small bowel involvement
• Diverting colostomy for refractory perianal
  disease

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• Encourage smokers with Crohns to quit at every
  encounter
• Offer smoking cessation aids
• Stress advantages better response to
  medications, lower rate of relapse, lower rate of
  post-op recurrence

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• Exclude infection such as C diff or CMV (in
  immunocompromised patients) with each flare-up
  and in refractory patients
• Stool for C diff toxin on three separate days
• Endoscopic biopsies for histology, immunostaining
  and culture

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• Know the benefits and risks of IBD therapy in
  pregnancy
• Drugs categorized as A,B,C, D and X
• Individualize therapy
• Refer to IBD specialist to discuss issues related
  to pregnancy and IBD and IBD medications and
  pregnancy
• Involve high-risk OB in discussions early (before
  conception if possible)

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IBD Drugs in Pregnancy