Meeting the Challenges of IBD Strategies for DOs By Joyce Flory, PhD ❚ Will I have a normal, healthy baby? Living with inflammatory bowel disease (IBD) is a challenge. The disease affects both men and women equally, according to the National Digestive Diseases Information Clearinghouse of the National Institutes of Diabetes and Digestive and Kidney Diseases within the National Institutes of Health. Osteopathic physicians can support female patients with IBD by recommending strategies for prevention; trouble-shooting problems related to sexuality, pregnancy and infertility; and staying up to date on pharmaceutical innovations and other research breakthroughs. Women, in particular, are interested in finding answers to several core questions, according to the World Journal of Gastroenterology (www.wjgnet.com). These include the following: ❚ Will my IBD flare up in pregnancy? ❚ Will I be able to have normal relationships and a family? ❚ Will my children inherit IBD? ❚ Will my fertility be impaired by IBD or its treatment? 4 ❚ Will I have to take drugs during pregnancy? ❚ Is breast-feeding advisable and safe? IBD and IBS: Root Differences Irritable bowel syndrome and inflammatory bowel disease are two conditions of the intestinal tract. They share some common symptoms such as pain and discomfort, urgency and bloating, and alteration of bowel habits. IBS is usually characterized as a functional disease or syndrome with a diagnosis made on a cluster of symptoms in the absence of notable structural abnormalities. IBD is a similar disorder, but it does differ in that it is a collection of disorders characterized by chronic mucosal and/or inflammation of the intestines IBD is more severe than IBS. IBS is alternately known as spastic colon, spastic colitis, mucous colitis, nervous stomach and nervous diarrhea. IBS is the number one digestive disease in America, with 30-50 million sufferers. Several theories explain IBS symptoms, says Geraldine O’Shea, DO, Foothills Women’s Medical Center, Jackson, California. One points to “exaggerated motor response to meals and neurohormonal stimulation,” while another suggests emotional tension and psychological factors. IBD is typically separated into two different diseases—Crohn’s disease (CD) and ulcerative colitis (UC). IBD is characterized by inflammation or ulceration, i.e., “organic” changes in the small and/or large intestines, which are not associated with IBS. The predominant symptom at the onset of ulcerative colitis is diarrhea––with or without blood in or on the surface of the stool, says Dr. O’Shea. Other symptoms include tenesmus, urgency, rectal pain, and passage of mucus without diarrhea. Patients with Crohn’s disease typically present with diarrhea as well as insidious abdominal pain in the right lower quadrant. However, bleeding is far less common than with ulcerative colitis. Prevention First DOs must help patients prevent the waves of pain, diarrhea and bleeding common to both Crohn’s disease and ulcerative colitis. “Therapies include drugs that control inflammation and such strateges as diet, exercise and stress management,” says Teresa Hubka, DO, of Chicago-based Comprehensive Women’s Care. Advise female patients to eat a healthy diet. “Women feel and look better when they eat a diet filled with complex carbohydrates,” says Dr. Hubka. “A realistic diet should include fruit, vegetables, fish, lean meat and carbohydrates such as whole grain breads, cereals and pasta.” Adhering to such a diet can prevent the dehydration, malnutrition and weight loss often found among women with IBD, adds Sheryl Bushman, DO, of Mercy Physicians Medical Group, Fort Smith, Ark. DOs may want to check out the dietary advice advanced by Michael F. Roizen, MD, and Mehmet Oz, MD, in their 2005 book YOU: The Owner’s Manual. Council female patients to listen to their bodies. “All IBD patients are not created equal,” says Dr. Bushman. Certain foods may have a severe, negative impact on some IBD patients but cause few or minimal problem for others. Dr. Bushman suggests that DOs avoid boilerplate recommendations such as “Stay away from red meat-or alcohol, hot sauces and milk.” Instead, allow the patient to try out certain foods and avoid or minimize those that pose a threat to health. Suggest a cautious approach to fiber. Patients look to their DOs to find out how much fiber they can consume without causing problems, advises Dr. O’Shea. Female patients experience a narrowing of the intestines, which could turn into an obstruction if too much fiber is consumed, according to the Crohn’s and Colitis Foundation of America (www.ccfa.org). Recommend a stress-management program. DOs should advise patients to avoid stress wherever possible—at home and at work,” says Dr. O’Shea. “Some IBD patients can track flare-ups to highstress events or prolonged periods of intense stress.” Among the strategies DOs can suggest are exercise, relaxing hobbies, and participation in real-world and online support groups. Drug Treatment Several groups of drugs are also used to treat patients with IBD. They are: 1. Aminosalicylates (5-ASA) This class of anti-inflammatory drugs includes sulfasalazine and oral formulations of mesalamine, such as Asacol(R), Colazal(R),. Dipentum(R), or Pentasa(R),. In addition, 5-ASA drugs also may be administered rectally Canasa(R) or Rowasa(R) in the form of suppositories or enemas. Sulfasalazine is the least expensive of the medications used, but many people are allergic or intolerant to it and can be limited by dose-related side effects. Asacol, the most commonly prescribed 5-ASA, is effective in the treatment of active UC and for the maintenance of remission. In clinical studies, patients who took Asacol had a side effect profile similar to patients who took placebo. These medications typically are used to treat mild to moderate symptoms. 2. Corticosteroids Prednisone and methylprednisolone are available orally and rectally. In addition, some steroids are available for intravenous use. Corticosteroids suppress the immune system and are used to treat moderate to severely active IBD. These drugs have significant short- and long-term side effects including hypertension, new onset diabetes, bone loss and fractures. Therefore they should not be used as a maintenance medication. If you cannot come off steroids without suffering a relapse of your symptoms, your doctor will need to add some other medications to help manage your disease. 3. Immune modifiers Azathioprine Imuran(R), 6-MP Purinethol(R), and methotrexate. Immune modifiers, sometimes called immunomodulators, are used to help decrease corticosteroid dosage and also to help heal fistulas. In addition, immune modifiers can help maintain disease remission. Physicians often prescribe these medications when a patient can’t stop taking steroids (due to disease flares). These drugs may take up to 3-4 months to work and have significant adverse events including malignancy. 4. Antibiotics This class includes metronidazole, ampicillin and ciprofloxacin among others. Antibiotics are not commonly used for UC, but they have been shown effective in treating patients with CD. 5. Biologic therapies In August 1998, the FDA approved the first biologic therapy for Crohn’s disease. This was infliximab [(Remicade(R)], which is indicated for moderately to severely active Crohn’s in patients who have not responded adequately to conventional therapy. It is also approved for reducing the number of draining enterocutaneous fistulas. And in September 2005, Remicade(R) received FDA approval for the treatment of UC as well. In June of 2002, infliximab was approved by the FDA for a new indication ––maintaining remission. Recently, studies 5 were completed that showed infliximab was also an effective therapy for patients with moderately to severely active UC that was unresponsive to other therapies. Infliximab is given by infusion. The biologics hold much promise for treating IBD, but they must be used with great caution. Patients can develop antibodies to the drug, may require life-long therapy and as a result, may have significant adverse effects such as malignancy, heart failure and increased risk for tuberculosis. Several other biologic agents for both Crohn’s disease and ulcerative colitis are being studied in clinical trials currently, but none are yet commercially available. Hubka. Traumatized by fears of painful intercourse and soiled sheets, these women can benefit from the compassion, support and practical advice from their DOs. Amber J. Tresca, an IBD patient featured as a guide to the irritable bowel and Crohn’s disease Web sites at About.com, suggests that DOs advise female patients to move their bowels prior to having intercourse (www.ibscrohns.about.com). Doing so can help women relax and enjoy the sexual encounter. Contraceptive Conversations: DOs may want to consider the notion that birth control pills may trigger CD in some women, says Dr. O’Shea. The data surrounding this issue is controversial but individual patients should be counseled on this risk. For more information, go to Answers. com, which reflects the diversity of opinion on the issue with this statement: “Some women find that their disease is exacerbated by taking the birth control pill, while others find it can help keep their flare-ups at bay.” In any case, several considerations need to be taken into account: ❚ If birth control is used, the patient should have a lower estrogen count. ❚ Avoid intermittent usage. Compliance with daily medication is important to avoid hormonal fluctuations. ❚ Avoid in women with known hypercoagulability with active IBD. ❚ Avoid in women with IBD-associated liver disease. Turning IBD Patients into Sexperts “Many women with IBD compromise their sex lives by making excuses to not have sex or avoiding sex entirely,” says Dr. 6 Others suggest that DOs help women investigate additional sources of pelvic pain, such as irritation of the pelvic nerves or a fissure or fistula (go to www.sexualhealthmatters.com). Equally important is reminding female IBD patients of the need for both lubrication and foreplay prior to sexual intercourse. 2004, issue of Medscape General Medicine (www.medscape.com). “Many women with IBD fail to give enough thought to the health of their partners when confronting fertility and pregnancy,” says Dr. O’Shea. For example, if the spouse or partner receives sulfasalazine as a treatment for his own IBD, the drug has the potential to reduce sperm motility and number as well as change sperm shape, according to a presentation made at the annual Digestive Disease Week (www. ddw.org). Only by stopping the drug for several months can the potential father produce the kind of sperm capable of penetrating an egg. While some physicians counsel women with IBD not to get pregnant, a growing number recognize that the majority of women can complete a pregnancy without increasing the severity of the disease or harming the baby, according to Medscape News (www.medscape.com). However, women must take IBD medications to avoid a relapse of the disease. Writing in Medscape General Medicine, two physician authors conclude that “active disease at conception increases the risk for adverse outcomes” and that “the majority of medications for IBD are safe in pregnancy and breastfeeding” (www.medscape.com). To that end, DOs may want to counsel IBD patients to become pregnant while the disease is in remission rather than during a flare-up, says Dr. Hubka. Also crucial is reinforcing the importance of staying on IBD medications during pregnancy, says Dr. Bushman. However, DOs must also urge patients to discuss any medication decisions with their OB-GYN. A Baby, Maybe “Women with IBD are often concerned about fertility, pregnancy and the health of their baby,” says Dr. Bushman. Fortunately, women with IBD tend not to have more severe fertility problems than women without the disease, according to Up to Date (www.patients.uptodate.com). An exception arises when inflammation spreads from the bowel to the ovaries and leaves scars in the women’s fallopian tubes, according to the authors of “IBD and Pregnancy,” which appeared in the Oct. 8, Stay Informed One of the best actions DOs can take is to stay up to date on clinical and research breakthroughs related to IBD. Among the most recent discoveries are the following: *Probiotics or “good bacteria” contain immune-system stimulating DNA, which makes them as effective when they are inactive as when they are eaten as live microorganisms in dairy products. Writing in the February 2004 issue of Gastroenterology), researchers at the University of California, San Diego (UCSD) School of Medicine and the Shaare Zedek Medical Center in Jerusalem believe they now have a mechanism to determine which probiotic bacteria can benefit patients with IBD. The result may be “better living through microbes,” according to a research synthesis appearing in the June 5, 2005, issue of Nature Biotechnology. 2005. Serious diseases that cause anemia include chronic kidney disease, diabetes, heart disease, cancer, rheumatoid arthritis, inflammatory bowel disease and HIV. “While IBD is a serious medical condition, DOs can remind patients that they have the power to live happy, productive lives with the right medical treatment and self-care,” says Dr. Hubka. Dr. Bushman agrees, adding, “DOs can alleviate many common anxieties by providing clear, candid answers to patients’ questions: ❚ ❚ ❚ ❚ ❚ What is this disease? What causes it? What are the signs and symptoms? How is it diagnosed and treated? How can I best care for myself or my family member?” “Wonderful progress is being made in the development of drugs for treating IBD,” says Dr. O’Shea. “The future is bright.” ❙ ww Professional Resources Crohn’s Colitis Foundation of America: Science & Professionals www.ccfa.org Changing Treatments reatment for IBD is changing, according to Research and Markets in their report, Inflammatory Bowel Disease: Efficacy and Compliance Key to Maximizing Patient Share as Novel Biologics Wait in the Wings. While biologics are making inroads, use of drugs such as steroids continues. Under discussion are issues that include the convenience of Humira, the lower cost of CDP870, and the safety of Tysabri. “Strong majorities of physicians believe Remicade is disease modifying, and that mesalamine products are chemopreventive,” write the authors of the report. Although Remicade can be disease modifying, there are many considerations such as adverse events—heart failure and TB— as well as antibodies that can render the drug useless. The Food and Drug Administration approved the first instant anemia test in June Gastrosource www.gastrosource.com Gastroenterology www.gastrojournal.org American College of Gastroenterology www.acg.gi.org Pediatric IBD Women patients will undoubtedly be interested in pediatric IBD. DOs can do much to reassure the parents of children with this condition through these steps: ❚ Approach the child and mother with sensitivity and respect. IBD is a source of emotional distress and embarrassment for children, often making it difficult for them to participate in routine activities such as school, sports or social occasions. Indicate your willingness to discuss symptoms openly with both the mother and/ or father and child. ❚ Perform a thorough physical exam, including blood tests to check for an inflammatory process or anemia. ❚ Make a referral to a pediatric gastroenterologist if the child’s symptoms and blood work suggest IBD or are inconclusive. ❚ Explain the role of diagnosing IBD through x-ray studies, such as an upper gastrointestinal series (upper GI), barium enema, and endoscopic procedures and biopsies. ❚ Explore the ambiguity of diagnosing IBD in young people, as well as the diagnosis of indeterminate colitis. American Gastroenterological Association www.gastro.org BioMed Central Gastroenterology www.biomedcentral.com Journal of Clinical Gastroenterology www.jcge.com American Journal of Gastroenterology www.amjgastro.com Medscape Gastroenterology www.medscape.com Evidence-Based Gastroenterology www.evidence-based-gastro.com 7