|
|
Inflammatory Bowel Disease |
Article Sections
Treatment
Steroids
FAQs |
Introduction
Two related disorders are referred to collectively as idiopathic inflammatory bowel disease (IBD). They are:
Ulcerative colitis (UC).
Both disorders are characterised by inflammation in the lining (mucosa) of the intestines.. The mucosa becomes inflammed and breaks (ulcers) may occur on the surface. In ulcerative colitis, the inflammation is restricted to the large intestines. In Crohn's disease, any part of the GI tract may be affected : from the mouth to the anus.
Symptoms
Excessive amounts of mucus containing pus may be produced and the intestinal lining may bleed. Hence common symptoms of inflammatory bowel disease are:
- Diarrhea
- bloody stools
- passage of mucous
Other symptoms include:
- fever
- weight loss
- abdominal pain
Why is it called "Idiopathic"?
While there are many theories, and tremendous progress is being made in research, the actual reason why a patient gets Idiopathic inflammatory bowel disease is still not known. Hence these 2 diseases are more accurately called Idiopathic (cause unknown) inflammatory bowel disease.
Treatment
Idiopathic IBD are chronic (life-long) diseases and as no cause has been found, there is also no definite cure. There are, however, effective drugs to control the disease and if properly managed, the patient lives a perfectly normal life. Medication however needs to be taken on a life long basis. The disease is known to undergo periodic flare ups (relapses) and inactive periods (remission). Life long medication aims to decrease the number of relapses a patient will suffer. Hence even if there are no symptoms, medication needs to be continued without fail. There is no way of predicting the actual pattern of remission and relapse in a particular patient. Every patient behaves differently.
The amount and type of medication needed changes, depending on the severity of the disease. These medications may be taken by mouth, injected directly into the veins, or applied directly into the intestines through the anus. The most effective method of giving the medication is dependant on which part of the intestines is affected.
The purpose of treatment is two-fold
1. to reduce the activity of the disease - medically this is called "inducing remission"
2. to maintain remission and minimize / prevent flare-ups (relapses)- medically this is called "maintenance therapy"
What drugs are used in IBD?
For induction of remission, higher dose of drugs will be used. Side effects, if they are to occur, are therefore more commonly experienced during this early phase of treatment. All side effects are however expected to reverse as doses are reduced.
During maintenance therapy, the number of drugs and the doses used will generally be lower and side effects are therefore also less common.
There are 3 major categories of drugs used in the treatment of idiopathic inflammatory bowel disease.
1. Drugs which have an effect on reducing the activity of the disease / inflammation: Steroids eg. prednisolone, hydrocortisone, 5-Aminosalicylates eg Salofalkâ, Pentasaâ, Salazopyrinâ, Immunosuppressants eg azathioprine (Imuranâ), 6-mercaptopurine (Puri-netholâ), methotrexate, cyclosporine, and others.
2. Drugs which are used to relief some particular symptoms of Idiopathic inflammatory bowel disease but which do not directly affect disease activity e.g. antidiarrhoeal medications and pain relief medications
3. Miscellaneous drugs, e.g. Vitamins, minerals, special nutritional solutions
Steroids
Steroids are the mainstay in the treatment of active disease. Steroids may be:
- taken by mouth (oral administration) in the form of tablets or capsules
- inserted directly into the rectum (topical administration) in the form of suppositories, liquid enemas, foam enemas.
- injected directly into the veins (intravenous administration) for severely ill patients.
You may be asked to use the rectal preparation along with oral treatment for better control of the disease.
ORAL STEROIDS
Steroids are given in gradually reducing doses (medically referred to as "tailing regimes"). Depending on the response, each reduction may take place at 2 weekly intervals or longer. It is vitally important that you understand how your physician wants you to take and tail the medication. If in doubt, always ask.
Unless instructed by your physician, YOU MUST NOT stop steroids abruptly as it is dangerous for you to do so. If you run out of medication for any reason before your next appointment, you MUST get an interim refill by a doctor who knows your case.
In the majority of cases, steroids will ultimately be terminated once the disease is in remission. However, in some patients, a low dose of steroid has to be maintained to keep the disease under control.
| Side effects of oral steroids
The possible side effects of oral steroids include:
- increased appetite/ weight gain
- mood swings
- fluid retention / facial bloating
- pimples (acne)
- elevation of blood sugar level (hyperglycemia) / worsening of underlying diabetes - if you are known to have diabetes and have been started on steroid therapy, you should step up the monitoring of your sugar level and see the doctor who is taking care of your diabetes more frequently. They can then monitor your diabetic condition more closely and advise on the need for diabetic drug dosage adjustments. It is very important for you to keep to a recommended diabetic diet.
- mild elevation of blood pressure - you should similarly see you own doctor to have your blood pressure closely monitored while on steroid therapy. As the dose of steroid is reduced, your blood pressure will return to its baseline level.
- "gastric" irritation - if you already are known to have a stomach or duodenal ulcer, steroids can exacerbate the symptoms. If this occurs, see you doctor as specific treatment may be required.
- thinning of bones (osteoporosis) may occur but only if steroids are taken for long periods of time at high doses. Menopausal women are particularly at risk. Discuss this with your doctor / pharmacist
- slowing down of growth rate of children
|
TOPICAL ( locally applied ) STEROIDS
These are steroid preparations which are administered directly, through the anus, to the site of the disease. They come in tablet forms (suppositories) or liquid / foam enemas. They are useful for treating patients where the site of inflammation is located near the rectum and last part of the colon. As they are not well absorbed into the body and mainly act locally in the intestines, they have less of the side effects mentioned above.
Rectal enemas / foams should be given just before bedtime in the lying position. This allows the contents to be retained for as long as possible so as to achieve better effects. You may experience bloating sensation or abdominal cramps. Adopting the correct technique of administration of enemas minimizes the discomfort.
Please ask your pharmacist if you need clarifications on administration techniques of the topical steroids.
5-AMINOSALICYLATES
These drugs are used for both inducing remission and maintenance therapy. Therefore, your doctor will advise you to continue taking these medicines for life even when your inflammation is no longer active and you actually feel normal. Relapse rates of ulcerative colitis and Crohn's disease has been shown to be high when you stop this medication.
There are a number of different preparations available eg. Sulphasalazine (Salazopyrinâ) and mesalazine (Salofalkâ and Pentasaâ). Although these medicines contain the same active component, the formulations are not similiar. Your doctor will decide which preparation will be most suitable for you.
Just like for steroids, 5-Aminosalicylates are available in both oral (tablets) and rectal preparations (suppositories, liquid & foam enemas). You may be asked to use the rectal preparation along with oral treatment for better control of the disease.
Some patients may experience some side effects of 5-aminosalicylates:
- "gastric" discomfort
- nausea
- frequency to defecate
- possible low sperm count (patients who are on sulphasalazine)
- anal irritation ( patients who are using rectal preparations)
IMMUNOSUPPRESSANTS
An overactivation of the body immune system is associated with IBD. These drugs are used to correct this problem
.
These drugs are useful in patients who are not responding well to steroids and 5- aminosalicylates. Their addition will help to reduce the total amount of steroids needed to control the disease and therefore also help reduce the side effects of steroids. Some common examples of immunosuppresants are azathioprine (Imuranâ) and 6-mercaptopurine (Puri-netholâ).
Azathioprine will only show a beneficial effect after several months of starting the medication.
The common side effects are:
- nausea
- fever
- skin rashes/bruising
- flu-like syndrome
- mouth ulcers
- If you experience the above side effects, you should inform your doctor.
Frequently Asked Questions
Will I require surgery?
Surgery may sometimes be indicated. The reasons for surgery for Ulcerative colitis and Crohn's Disease are not entirely similar but they do overlap. As and when they occur, your doctor will discuss the details with you. Generally, surgery may be required for the following reasons :
- a severe episode of IBD that is not responding despite intensive medical treatment
- patients who suffer from frequent repeated episodes of attacks and are not responding well to medical treatment;
- involvement of other organs eg. joints, eyes.
- pre-cancer changes are noted in the intestines
- blockage of the intestines (intestinal obstruction)
- leakage of the intestines and infection (perforation and abscess formation)
- uncontrolled bleeding (haemorrhage)
- Development of an abnormal connection between the intestines with other organs or the skin (fistula)
See Colorectal department website for surgical therapy in IBD.
How will IBD affect me?
Except for severe relapses of the disease, you will probably not require hospitalisation or medical leave from work. However, you may have to make adjustments in work, domestic and social routines and activities in order to cope with medication timings and the occasional flare up of symptoms.
It requires:
- life long medication and regular follow up
- you to take an active interest in the disease, understand your medication and their side effects
- compliance with medication
In the majority of patients it can be effectively controlled, and it is compatible with a normal life style and normal life span.
Can I travel?
You should avoid travelling during periods of IBD relapse because of the inconvenience of frequent toilet visits, medications and abdominal pain.
When travelling abroad, you should always ensure that you have ADEQUATE supply of medicine. As it is a chronic disease, it is a good practice to remember both the names and doses of the medication that you are currently on. Alternatively bring along the labels of your medicine. It will be helpful in case your supply runs out and you need to see a local doctor to obtain emergency supplies.
Store the drugs in a cool, dry place away from direct sunlight. A tablet organizer which is available at any retail pharmacy may be helpful in sorting out your daily medicine intake.
When traveling to a country on another time zone, you should take the medication according to their local time.
Always carry at least some of your medication in the hand-carry case. This is a precautionary measure in case your check in luggage is lost / misplaced.
Is IBD influenced by diet?
There is no need for any specific dietary adjustments for most patients with IBD. Food types have NO relationship to disease flares. In particular, you are encouraged to maintain a well balanced diet and food fads are strongly discouraged.
Is sexual function affected by ibd?
There are 2 aspects of sexual function that needs to be addressed:
- Sexual performance
- Fertility
Sexual Performance:
As long as your IBD is under control, the disease should not stop you from having a normal healthy sex life. However, some symptoms of IBD and psychological factors eg. having a poor body image, stoma, operation scars may affect your sexual life. For some male patients who have had to undergo surgery, impotence may be a complication. If you have any problems, discuss them with your doctor.
Fertility for men
Sperm quality may be reduced during severe disease activity. However, these problems are usually temporary and should restore to normal as control of the disease is achieved. Sulphasalazine, a commonly used drug may also cause decrease in sperm count and quality. The effects are temporary and the sperm count should return to normal 2 or 3 months after stopping the medication. Substitute medication without this side effect is available and may be used in place of sulphasalazine where indicated. Sulphasalazine does not increase the risk of having abnormal children. If you are on the drug and your partner is unable to conceive, you should discuss the problem with your doctor.
Fertility for women
If the IBD is under good control, normal ovarian function is expected. Normal fertility and normal fetal outcomes with no increase in miscarriages (abortions) and abnormal babies (malformations) are to be expected. The pregnancy does not require any special care although early consultation with an obstetrician is encouraged so that he / she is aware of your underlying IBD.
However, you are strongly discouraged from getting pregnant before the disease is under optimal control as active disease may adversely impact on the outcome of the pregnancy both for yourself and the baby. It is essential that you plan and time your pregnancy. If you are planning to get pregnant, discuss this with your doctor well in advance.
It is important that you practice proper contraception when the disease has not reached optimal control yet. Because of the potential adverse effect of oral contraceptives on some types of Idiopathic inflammatory bowel disease, barrier contraception e.g. condoms is preferred. If you wish to take oral contraception pills, consult your doctor before starting.
Virtually all the commonly used drugs in IBD have not been shown to have harmful effects on female fertility or the unborn baby (fetus). It should be emphasized that the major threat to pregnancy comes from the disease itself and not from the medication. Therefore it is very important for you to continue taking your medicines regularly even if you are pregnant. Disease control is vital for success of your pregnancy.
However, some of the drugs used in Idiopathic inflammatory bowel disease therapy may potentially have adverse effects on the foetus. It is important that your doctor be made aware of your intention to have a child before you conceive so that such drugs are substituted or modified in dose before conception
Will my children inherit the disease?
Genetics do play a part in Idiopathic inflammatory bowel disease but the inheritance is not straight forward. Furthermore, even if "bad" genes are inherited, the disease may not occur. This is because external factors still play an important role. Hence, only estimates of potential risk of passing on the disease to the next generation can be given. The risk is generally low and there is NO reason why you should not consider having children just because you have IBD. At the moment, we cannot identify which fetus will develop the disease in later life at the pre-delivery stage. Hence, unlike certain diseases (eg. Thalassaemia, Mongolism), perinatal screening and therapeutic abortion is not an available option.
Can I breastfeed while on medication?
Most drugs used in IBD are safe during breastfeeding. The drugs are usually secreted in very tiny amount in the breast milk and therefore would not have any harmful effect on your baby. Breastfeeding is not discouraged but discuss this with your doctor before you proceed.
Is this cancer?
IBD is not a form of bowel cancer. However, patients who have had IBD for many years (at least 10 years or more) have an increased risk of developing intestinal cancer, particularly cancer of the large intestines. At a certain point of time in the course of the disease and depending on your specific type of disease, regular colonoscopy will be recommended to detect early cancer. This called cancer surveillance and usually it is performed on a yearly basis. Surgery may be recommended for high risk patients.
Is IBD infectious?
NO. There is no need to segregate your personal articles and food nor keep away from your family members.
|