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Diagnosis and Management of IBD
Orlando, FL—Inflammatory bowel disease (IBD) affects more than 1 million people in the United States. IBD encompasses a variety of clinical signs and symptoms including abdominal pain, diarrhea, and rectal bleeding. Presenting symptoms range from mild to severe and the clinical course is often unpredict- able ranging from easily controlled to fulminant disease. Crohn’s disease and ulcerative colitis (UC) are the 2 most common forms of IBD; however, other overlapping conditions are also included.
During a session at the NAMCP Forum, Joel R. Rosh, MD, director, pediatric gastroenterology, Goryeb Children’s Hospital/Atlantic Health, and professor of pediatrics, Icahn School of Medicine at Mount Sinai, discussed the diagnosis and management of IBD.
Patients with IBD may have unique signatures that predict complicated or treatment refractory disease, he explained. Genetic susceptibility includes family history, host genetics, and gene expression. Immune response includes innate response, adaptive response, and serological response. Treatments include biologics, surgery, pharmacogenomics, monitoring, and adherence. Environmental factors include microbiome, smoking, stress, nonsteroidal anti-inflammatory drugs, and diet. Diagnosis of IBD is made with a combination of modalities, including radigraphic, endoscopic, and pathologic studies. Dr Rosh highlighted management goals for IBD:
• Relieve symptoms
• Treat inflammation
• Treat complications
• Minimize treatment toxicity
• Address psychosocial issues
• Identify dysplasia and detect cancer
• Improve daily functioning
• Replenish nutritional deficits
• Maintain remission
There are 5 main categories of medications used to treat IBD: (1) aminosalicylates, (2) corticosteroids, (3) immunomodulators, (4) antibiotics, and (5) biologic therapies. He discussed aminosalicylate formulations used in IBD (Table). These are anti-inflammatory compounds that contain 5-aminosalicylic acid (5-ASA). These drugs (given orally or rectally) act to decrease inflammation at the wall of the intestine.
While the cornerstone of therapy for mild to moderate UC is 5-ASA therapy, the evidence of efficacy in Crohn’s disease is very limited, said Dr Rosh. He cited a study of 5-ASA therapy in newly diagnosed pediatric UC [J Pediatr Gastroenterol Nutr. 2013;56(1):12-18]. The study included 213 patients newly diagnosed with UC who received oral 5-ASA compounds. The primary endpoint was corticosteroid-free, inactive UC at 1 year following initiation of 5-ASA within 30 days of diagnosis (with or without concomitant corticosteroid use) without the need for rescue therapy (immunomodulators, biologics, or col- ectomy). Forty percent of children taking 5-ASA as primary maintenance therapy at diagnosis were in corticosteroid-free remission after 1 year of treatment.
Dr Rosh also touched on predictors of poor outcomes in Crohn’s disease, citing a study by Beaugerie et al [Gastroenterology. 2006;130(3):650-656]. The aim of the study was to identify, at diagno- sis, factors predictive of a subsequent 5-year disabling course among 1123 patients. The rate of disabling disease was 85.2%. Independent factors present at diagnosis and significantly associated with subsequent 5-year disabling were the initial requirement for steroid use (odds ratio [OR] 3.1; 95% confidence interval [CI]: 2.2-4.4), an age below 40 years (OR 2.1; 95% CI: 1.3-3.6), and the presence of perianal disease (OR 1.8; 95% CI: 1.2-2.8).
For IBD, “step in” therapy rather than sequential therapy is the best strategy to change the natural history and disabling outcome of surgery, hospitalization, and lower quality of life, Dr. Rosh said. Along with personalized approach of risk stratification, treat to target is emerging as a best practice for IBD. Treat-to-target goals include regular assessment of disease activity using objective clinical and biologic outcome measures, adjustment of treatment if goal is not being accomplished, and enabling better outcomes in rheumatoid arthritis, hypertension, diabetes, and hypercholesterolemia.
Novel technological advances to assess disease activity in IBD are being used. Dr Rosh said that advances in small bowel imaging include magnetic resonance enterography, computed tomography enterography, and video capsule endoscopy.
“Therapeutic drug monitoring, optimization of therapy, and tight monitoring of actual disease activity (not just symptoms) are critically important goals,” said Dr Rosh. “Treatment of the whole patient will result in best overall outcomes.”—Eileen Koutnik-Fotopoulos
