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Ten Pearls for Treating IBD

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Use the right drug for the right reason at the right dose. Goals. Achieve remission ... Endoscopic biopsies for histology, immunostaining and culture #10 ... – PowerPoint PPT presentation

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Title: Ten Pearls for Treating IBD


1
Ten Pearls for Treating IBD
  • Debra J. Helper MD
  • Associate Professor Clinical Medicine
  • Indiana University School of Medicine

2
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

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

4
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

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

6
5
  • 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.

7
6
  • 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

8
7
  • 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

9
8
  • 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

10
9
  • 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

11
10
  • 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)

12
IBD Drugs in Pregnancy
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