Medical Management Of Crohns Disease
The severity of CD is more difficult to assess than UC. The general principles are to consider the site , pattern and activity of the disease before treatment decisions are made in conjunction with the patient.
An alternative explanation for symptoms other than active disease should be considered and disease activity confirmed before starting steroids. Individuals with CD have many investigations over their lifetime and imaging should not be repeated unless it will alter management or a surgical decision depends on the result.
Patients should be encouraged to participate actively in the decision to treat with high dose aminosalicylates, different corticosteroids, nutritional therapy, antibiotics, new biological agents, or surgery. Infliximab is considered in section 6.5.
Drugs Used In The Treatment Of Ibd
Therapy for IBD is a rapidly evolving field, with many new biological agents under investigation that are likely to change therapeutic strategies radically in the next decade. Details of the principal drugs can only be summarised in this document.
, mesalamine in the USA.) Different formulations deliver millimolar concentrations to the gut lumen. Aminosalicylates are available as oral tablets, sachets or suspension, liquid or foam enemas, or suppositories. They act on epithelial cells by a variety of mechanisms to moderate the release of lipid mediators, cytokines, and reactive oxygen species. Oral forms include:
pH dependent release/resin coated
time controlled release
delivery by carrier molecules, with release of 5-ASA after splitting by bacterial enzymes in the large intestine , olsalazine , balsalazide ).
Adverse effects of 5-ASA
, or intravenous hydrocortisone, methylprednisolone.) Topical suppositories, foam or liquid enemas include hydrocortisone, prednisolone metasulphobenzoate, betamethasone, budesonide). Many strategies attempt to maximise topical effects while limiting systemic side effects of steroids. Budesonide is a poorly absorbed corticosteroid with limited bioavailability and extensive first pass metabolism that has therapeutic benefit with reduced systemic toxicity in ileocaecal CD, or UC.
Choice and mechanism
Efficacy for active UC
Efficacy for active CD
Other Recommendations For Research
Induction of remission for people with moderate ulcerative colitis: prednisolone compared with aminosalicylates
What is the clinical and cost effectiveness of prednisolone compared with aminosalicylates for the induction of remission for people with moderate ulcerative colitis?
Induction of remission for people with moderate ulcerative colitis: prednisolone compared with beclometasone
What is the clinical and cost effectiveness of prednisolone plus an aminosalicylate compared with beclometasone plus an aminosalicylate for induction of remission for people with moderate ulcerative colitis?
Induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids
What are the benefits, risks and cost effectiveness of methotrexate, ciclosporin, tacrolimus, adalimumab and infliximab compared with each other and with placebo for induction of remission for people with subacute ulcerative colitis that is refractory to systemic corticosteroids?
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Information About Treatment Options For People Who Are Considering Surgery
These recommendations apply to anyone with ulcerative colitis considering elective surgery. The principles can also be applied to people requiring emergency surgery.
Information when considering surgery
For people with ulcerative colitis who are considering surgery, ensure that a specialist gives the person and their family members or carers information about all available treatment options, and discusses this with them. Information should include the benefits and risks of the different treatments and the potential consequences of no treatment.
Ensure that the person and their family members or carers have sufficient time and opportunities to think about the options and the implications of the different treatments.
Ensure that a colorectal surgeon gives any person who is considering surgery and their family members or carers specific information about what they can expect in the short and long term after surgery, and discusses this with them.
Ensure that a specialist gives any person who is considering surgery and their family members or carers information about:
- the type of surgery, the possibility of needing a stoma and stoma care.
Ensure that a specialist who is knowledgeable about stomas gives any person who is having surgery and their family members or carers specific information about the siting, care and management of stomas.
Information after surgery
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Drug Treatment After 57 Days
- Change IV hydrocortisone to: prednisolone oral 40mg each day. Reduce no faster than by 5mg every 57 days. Normally there is gradual reduction over a 48 week period if CRP and stool frequency falling.
- If ulcerative colitis add mesalazine oral :
- Salofalk® MR granules 1.5-3g once daily or in three divided doses .
- Pentasa® MR tablets / sachets 24g once dailyor
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Infliximab For Acute Exacerbations Of Ulcerative Colitis
Technology appraisal guidance
Evidence-based recommendations on infliximab for treating acute exacerbations of severely active ulcerative colitis in adults.
The recommendations also apply to infliximab biosimilar products that have a marketing authorisation allowing the use of the biosimilar for the same indication.
Chronic Active And Steroid Dependent Disease4559697191103
Long term treatment with steroids is undesirable. Patients who have a poor response to steroids can be divided into steroid refractory and steroid dependent. Steroid-refractory disease may be defined as active disease in spite of an adequate dose and duration of prednisolone and steroid dependence as a relapse when the steroid dose is reduced below 20 mg/day, or within 6 weeks of stopping steroids. Such patients should be considered for treatment with immunomodulators if surgery is not an immediate consideration.
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Proctosigmoiditis Causes And Risk Factors
Proctosigmoiditis is a result of chronic inflammation in the colon, like all types of ulcerative colitis. This inflammation is the result of an immune response. Doctors dont know what triggers this immune response.
Some people are more likely than others to develop ulcerative colitis. The risk factors for all types of ulcerative colitis are the same. They include:
- having a family history of ulcerative colitis
- having a history of infection with Salmonella or Campylobacter bacteria
- living at a higher latitude
- living in a developed nation
These factors only increase the risks for ulcerative colitis. Having one or more of these risk factors doesnt mean youll get the condition.
How Is Acute Severe Ulcerative Colitis Treated
ASUC is a challenging condition to treat. Once you’re admitted to the emergency room, you’ll get a series of tests, including blood tests, stool tests, and an exam of your bowel called a sigmoidoscopy. You’ll also get intravenous fluids to boost hydration.
The average hospital stay for ASUC treatment ranges from 4.6 to 12.5 days. During this time, your health care providers may include a gastroenterologist, colorectal surgeon, dietitian, pharmacist, and stomal therapist. The goal of hospitalizing you is to end the flare, get your symptoms under control, and put the disease into remission. Your doctors will want to make sure that rectal bleeding and diarrhea have stopped and normal bowel movements have returned. Rehospitalization is common.
Intravenous steroid medications are the most common treatment for ASUC. For 30% to 40% of ASUC patients, steroid treatments donât work â and taking steroid medications for more than 10 days increases your risk of complications.
If the steroids donât help within 3 to 5 days, your health care team will start âmedical rescue therapyâ with immunosuppressive drugs like cyclosporine or infliximab.
You might get an operation to remove part of your colon, called a colectomy, if your ASUC doesnât respond to steroids, immunosuppressants, or other medical treatments.
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Inducing Remission In People With Ulcerative Colitis
To induce remission in people with a first presentation or inflammatory exacerbation of proctitis, offer a topical aminosalicylate as first-line treatment.
If further treatment is needed, consider adding a of a topical or an oral corticosteroid.
For people who decline a topical aminosalicylate:
- consider an oral aminosalicylate as first-line treatment, and explain that this is not as effective as a topical aminosalicylate
- if remission is not achieved within 4 weeks, consider adding a time-limited course of a topical or an oral corticosteroid.
For people who cannot tolerate aminosalicylates, consider a time-limited course of a topical or an oral corticosteroid.
Proctosigmoiditis and left-sided ulcerative colitis
To induce remission in people with a mild-to-moderate first presentation or inflammatory exacerbation of extensive ulcerative colitis, offer a topical aminosalicylate and a high-dose oral aminosalicylate as first-line treatment.
If remission is not achieved within 4 weeks, stop the topical aminosalicylate and offer a high-dose oral aminosalicylate with a time-limited course of an oral corticosteroid.
For people who cannot tolerate aminosalicylates, consider a time-limited course of an oral corticosteroid.
The multidisciplinary team
Active Left Sided Or Extensive Uc22283237394776
For the purposes of these guidelines, left sided disease is defined as disease extending proximal to the sigmoid descending junction up to the splenic flexure and extensive UC as extending proximal to the splenic flexure. Disease activity should be confirmed by sigmoidoscopy and infection excluded, although treatment need not wait for microbiological analysis.
For the treatment of active, left sided, or extensive UC:
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Predictors Of Response To Steroids
Response to steroids is indicated by improvement in patients symptoms and improved laboratory parameters .
At day 3 of admission, response to steroids should be measured by assessing stool frequency and CRP levels .1). In the landmark study by Travis et al, which included patients with 51 episodes of severe UC, presence of more than 8 stools/d or 3-8 stools/d plus a CRP > 45 mg/L at day 3 predicted a colectomy rate of 85%. In another prospective study by Lindgren et al which included 97 episodes of severe UC, the following mathematical model was devised to predict colectomy: number of stoolsd + 0.14 × CRP 8 predicted a colectomy rate of 72%.
Algorithm for treatment decisions for patients with acute severe ulcerative colitis on intensive steroid therapy. AZA: Azathioprine.
Therefore regular assessment of response to steroids is of paramount importance in treating patients with acute severe UC. In a group of 80 patients who underwent emergency colectomy for severe UC between 1994 and 2000 in Oxford, patients with signicantly longer duration of preoperative medical therapy were more likely to have major post-operative complications.
What Are The Long
The long-term outlook for ASUC is guarded. There is a 20% chance that you’ll need colectomy surgery after your first hospitalization, but that chance rises to 40% after two hospital admissions for ASUC. Severe flares are linked to a 1% risk of death.
Older age is linked with higher death rates. The death rate from ASUC is over 10% in people over 80 compared to fewer than 2% for people between the ages of 50 and 59.
UC is a chronic disease with no cure. Developing acute, severe symptoms is a risk for up to 20% of those diagnosed with the disease. With hospitalization, medical management, and a knowledgeable health care team, you can recover from a bout of ASUC and go into remission, but new flares are possible.
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Patient Information And Support
1.1.1 Discuss the disease and associated symptoms, treatment options and monitoring:
with the person with ulcerative colitis and their family members or carers and
within the multidisciplinary team at every opportunity.Apply the principles in the NICE guideline on patient experience in adult NHS services.
1.1.2 Discuss the possible nature, frequency and severity of side effects of drug treatment for ulcerative colitis with the person, and their family members or carers . Refer to the NICE guideline on medicines adherence.
1.1.3 Give the person, and their family members or carers information about their risk of developing colorectal cancer and about colonoscopic surveillance, in line with the NICE guidelines on colorectal cancer prevention: colonoscopic surveillance in adults with ulcerative colitis, Crohn’s disease or adenomas and suspected cancer: recognition and referral.
Fistulating And Perianal Disease72739596
Active perianal disease or fistulae are often associated with active CD elsewhere in the gastrointestinal tract. The initial aim should be to treat active disease and sepsis. For more complex, fistulating disease, the approach involves defining the anatomy, supporting nutrition, and potential surgery. For perianal disease, MRI and examination under anaesthetic are particularly helpful.
Metronidazole 400 mg tds and/or ciprofloxacin 500 mg bd are appropriate first line treatments for simple perianal fistulae.
Azathioprine 1.52.5 mg/kg/day or mercaptopurine 0.751.5 mg/kg/day are potentially effective for simple perianal fistulae or enterocutaneous fistulae where distal obstruction and abscess have been excluded .
Infliximab should be reserved for patients whose perianal or enterocutaneous fistulae are refractory to other treatment and should be used as part of a strategy that includes immunomodulation and surgery .
Surgery , including Seton drainage, fistulectomy, and the use of advancement flaps is appropriate for persistent or complex fistulae in combination with medical treatment .
Elemental diets or parenteral nutrition have a role as adjunctive therapy, but not as sole therapy .
There is insufficient evidence to recommend other agents outside clinical trials or specialist centres.
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Treatment Comparators And Clinical Practice
According to the Dutch guidelines for pharmacoeconomic research , a drug should be compared with the standard or usual treatment for which effectiveness has been proven. UC patients hospitalized with an acute exacerbation currently receive IV corticosteroids in addition to their existing immunomodulator therapy. A total of 25% of these patients fail IV steroids and require further medical intervention . Following Dutch guidelines, cyclosporine and surgery were chosen as the treatment comparators .
In general, patients with an acute exacerbation of UC will receive 72 h 4060 mg/day IV prednisolone. Patients refractory to the initial treatment are assumed to receive one of the three identified treatment strategies comprising infliximab, cyclosporine or surgical intervention. Responders to medical treatments were assumed to be discharged from the hospital on the 10th day and moved to an outpatient setting. Patients not responding to medical treatments on or before the 10th day were assumed to progress to surgery.
Infliximab treatment included a first infusion of 5 mg/kg of infliximab on day 4, followed by additional 5 mg/kg infusion doses at week 2 and 6 after the first infusion. Patients on infliximab are expected to respond within 7 days of the first infusion. Following discharge from hospital, all infliximab responders received oral azathioprine for the rest of the 3-month period.
Patients undergoing surgical intervention do not receive concomitant medication .
Definition Of Effectiveness Evaluation And Cor
All moderate to severe active events in UC patients were classified as an effectiveness evaluation cohort for assessing the clinical outcomes of treatments during induction of, and maintaining remission after, excluding events that were inducted by 5-ASA alone. COR-REF or DEP cohorts were defined when any of the following conditions were observed: met the abovementioned criteria of COR-REF or DEP after taking corticosteroids for moderate to severe exacerbations or had a previous history of the criteria of COR-REF or DEP inducted for exacerbations using treatments without corticosteroids.
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Acute Exacerbation Of Ulcerative Colitis
Rectal Treatment for distal ulcerative colitis only
Mesalazine enema – 1st choice for distal colitisAvailable as:
Salofalk® mesalazine rectal foam
Dose: Mild ulcerative colitis affecting sigmoid colon and rectum, 2 metered applications into the rectum at bedtime or in 2 divided doses
|Dose: Pentasa® Mesalazine Enema: One enema administered at bedtime|
|Mesalazine suppositories 1g Available as:|
Salofalk® 1g suppositories
Dose: Acute mild to moderate ulcerative proctitis, one Salofalk 1g suppository once daily inserted into the rectum
Dose: Acute mild to moderate proctitis, one Octasa 1g suppository once daily inserted into the rectum
Oral mesalazine Available as:Octasa® M/R tablets 400mg, 800mg, 1600mg
|Pentasa® M/R tablets 500mg, 1g sachets 1g, 2g, 4g||Pentasa® M/R tablets: acute treatment, up to 4g daily once daily or in divided doses|
|Salofalk granules, 1.5g, 3g sachets||Salofalk m/r granules: 1.5-3g once daily, dose preferably taken in the morning|
|2nd line||Prednisolone tablets 1mg, 5mg||Dose: 30-40mg daily for 1 week, reducing by 5mg weekly thereafter according to patient response|
Diet Tips During A Flare
A modified diet may help you manage and reduce your UC symptoms. Depending on the person, specific foods may trigger flare-ups or worsen symptoms. As a result, its important to identify and limit these foods.
Your doctor and a dietitian can work with you to find a diet that best manages your symptoms while providing the nutrition you need.
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What Is A Uc Flare
A UC flare is an acute worsening of the symptoms of bowel inflammation. Flares may occur weeks, months, or even years apart, with different levels of severity.
Medication, your lifestyle, diet, and other factors may contribute to flare-ups. In the same way, taking all prescribed medications, eating balanced meals, and avoiding known triggers can often help prevent flares.
Ulcerative colitis symptoms change based on the severity of a flare-up and the location of inflammation in the intestine. Symptoms often include:
- moderate to severe abdominal pain or cramps
- persistent bowel movements