IBD Often Responds to Combination Therapy

Pharmacy Times, April 2022, Volume 88, Issue 4

Inflammatory bowel disease has complex treatment options, but pharmacists can help patients make the right choice.

Inflammatory bowel disease (IBD) is a term that encompasses 2 conditions that are characterized by inflammation of the gastrointestinal (GI) tract: Crohn disease and ulcerative colitis.1

This prolonged inflammation can wreak havoc on the GI system.

Individuals of any age can get IBD, but it is usually diagnosed between aged 15 and 40 years.2

Crohn Disease

Crohn disease can affect any part of the GI tract, from the mouth to the anus, but most often affects the portion of the small intestine just before the large intestine. Damage to the area occurs in patches located next to areas of healthy tissue. This inflammation may occur through multiple layers of the walls of the GI tract.1

Crohn disease affects men and women equally, and the disease occurs in all ethnic groups. Although diet and stress can aggravate Crohn disease, they do not cause it.3

Ulcerative Colitis

Ulcerative colitis occurs in the anus and large intestine. The damage is continuous, as opposed to patchy, and usually begins in the anus and travels farther up the colon. This inflammation is limited to the innermost layer of tissue.1

If left untreated, the disease often relapses and remits mucosal inflammation. Most patients with ulcerative colitis experience a mild to moderate course. However, 20% of patients may require hospitalization for severe disease activity.4

Statistics

An estimated 1.3% of adults in the United States, or about 3 million people, reported receiving an IBD diagnosis in 2015. This was an increase from 1999 when just 0.9% of the population reported having IBD. These estimates do not include children under aged 18 years who receive an IBD diagnosis.5

Also worth noting, compared with patients without IBD, patients who have the disease are more likely to have certain chronic health conditions, such as arthritis, cancer, cardiovascular disease, kidney disease, liver disease, migraines or severe headaches, and respiratory disease.5

Symptoms

The symptoms of IBD vary but are similar between the 2 conditions. These include persistent abdominal cramping and pain, constipation, delayed development and growth in children, diarrhea, fatigue, feeling of incomplete bowel evacuation, loss of appetite, rectal bleeding, urgent need to void bowels, and weight loss.6,7

Non-GI symptoms of Crohn disease include kidney stones, mouth sores, osteoporosis, painful or swollen joints, pain or redness in the eyes, skin bumps, rashes, sores, and vision changes.6

Non-GI symptoms of ulcerative colitis include anemia, fever, and nausea.7

Causes

Although the exact cause of IBD is unknown, it is thought to be a combination of factors, including autoimmune and genetic.8

Cigarette smoking is the most important controllable risk factor in developing Crohn disease, though it may prevent ulcerative colitis. It is important to note that smoking’s harm to overall health outweighs any benefits.8

Diagnosis

IBD is diagnosed using a combination of endoscopy for Crohn disease or colonoscopy for ulcerative colitis and imaging studies, such as computed tomography, contrast radiography, and magnetic resonance imaging. Physicians may also order blood tests to check for anemia and stool tests to rule out infection.1

Treatment

There is no cure for IBD but a combination of treatment options may help patients maintain control of their disease and lead full and rewarding lives. The primary goals of treatment are to control symptoms and regulate the immune system. Treatment is multifaceted and includes alterations in diet and nutrition, medication, and sometimes surgery.9

It is important to maintain a healthy, soothing diet to help reduce symptoms and promote healing. Foods that can trigger IBD and should be avoided include those high in fat, insoluble fiber, lactose, nonabsorbable sugars, sugar, and spices. Foods that patients should eat to promote a healthy gut in IBD include fruits, lean proteins, probiotics, vegetables, and those that are calcium- and fiber-rich.10

In addition to diet, IBD treatment usually involves drug therapy, surgery, or both. Drug therapy usually starts with anti-inflammatory agents, such as aminosalicylates (eg, balsalazide, mesalamine, and olsalazine) and corticosteroids. The choice between the two is typically driven by the location of the inflammation.8

Immune system suppressors work in many ways to suppress the immune response. The immune response, when activated, can release inflammation-inducing chemicals that can damage the lining of the GI tract. Some examples include azathioprine, mercaptopurine, and methotrexate.8

Biologics are newer therapeutic agents directed toward neutralizing inflammation-causing proteins. Some are administered intravenously, and patients can inject others on their own. Examples include adalimumab, certolizumab, golimumab, infliximab, ustekinumab, and vedolizumab.8

Antibiotics can be used in conjunction with other medications when infection is a concern. The most prescribed antibiotics used in IBD include ciprofloxacin and metronidazole.8

Other medications can be used to treat the signs and symptoms of IBD, including antidiarrheal medications, pain relievers, supplements, and vitamins.

If dietary changes and medications do not relieve symptoms, a physician may recommend surgery. The surgery for Crohn disease differs from the surgery for ulcerative colitis.8

Up to 66% of Crohn disease patients require surgery at some point. However, this does not cure the disease and the benefits are usually temporary. The surgery for Crohn disease involves resecting damaged portions of the bowels and stitching the healthy parts back together again. Surgery can also be used to close fistulas and drain abcesses.8

Surgery for ulcerative colitis involves the removal of the entire colon and the rectum. An internal pouch is constructed and attached to the anus for evacuation without a bag. Unfortunately, sometimes a pouch cannot be constructed. In these cases, the surgeon creates a permanent opening in the abdomen, or ileal stoma, through which stool is passed for collection into a bag.8

IBD is complicated and has complicated treatment options. Pharmacists can help patients make informed decisions about their treatment by educating them about the medications available and letting them know what to expect with surgery.

Kathleen Kenny, PharmD, RPh, has more than 25 years of experience as a community pharmacist. She is a freelance clinical medical writer based in Colorado Springs, Colorado.

References

1. What is inflammatory bowel disease (IBD)? CDC. Updated March 22, 2018. Accessed March 8, 2022. https://www.cdc.gov/ibd/what-is-IBD.htm

2. Inflammatory bowel disease. National Health Service. April 15, 2020. Accessed March 8, 2022. https://www.nhs.uk/conditions/inflammatory-bowel-disease/

3. Overview of Crohn’s disease. Crohn’s & Colitis Foundation. Accessed March 8, 2022. https://www.crohnscolitisfoundation.org/what-is-crohns-disease/ overview

4. Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020;158(5):1450-1461. doi:10.1053/j.gastro.2020.01.006

5. Inflammatory bowel disease (IBD) in the United States. CDC. Updated November 9, 2021. Accessed March 8, 2022. https://www.cdc.gov/ibd/data-statistics.htm

6. Signs and symptoms of Crohn’s disease. Crohn’s & Colitis Foundation. Accessed March 8, 2022. https://www.crohnscolitisfoundation.org/what-is-crohns-disease/symptoms

7. Signs and symptoms of ulcerative colitis. Crohn’s & Colitis Foundation. Accessed March 8, 2022. https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis/symptoms

8. Inflammatory bowel disease (IBD). Mayo Clinic. Accessed March 8, 2022. https://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/symptoms-causes/syc-20353315

9. Ulcerative colitis treatment options. Crohn’s & Colitis Foundation. Accessed March 8, 2022. https://www.crohnscolitisfoundation.org/ what-is-ulcerative-colitis/treatment-options

10. What should I eat? Crohn’s & Colitis Foundation. Accessed March 8, 2022. https://www.crohnscolitisfoundation.org/diet-and-nutrition/what- should-i-eat