Guidelines for the management of inflammatory bowel disease in adults continued

Management

Ulcerative colitis

• Disease activity and extent determine therapy:
  • severe: admit to hospital
  • mild/moderate: treat as outpatient
  • proctitis/disease extending to the sigmoid: topical management
  • more widespread: oral or parenteral treatment; additional topical therapy may help

• Active left-sided or extensive ulcerative colitis:
  • mesalazine, balsalazide, or prednisolone

• Active proctitis:
  • topical mesalazine or topical steroid plus oral mesalazine or corticosteroids

• Severe ulcerative colitis:
  • admit to hospital

• Maintenance of remission:
  • aminosalicylates, azathioprine or mercaptopurine
  • long-term treatment with corticosteroids is unacceptable

Crohn's disease

• Treat according to site, pattern and activity of disease and patient preference
  • exclude other causes of symptoms before starting new therapies
  • smoking cessation should be strongly advised before discussion of any drug therapy

• Active ileal/ileocolonic/colonic disease:
  • corticosteroids

• Fistulating and perianal disease:
  • metronidazole and/or ciprofloxacin, azathioprine, or infliximab (second-line)
  • surgery (adjunct to medical therapy) may be necessary

• Other sites:
  • oral: requires specialist management
  • gastroduodenal: proton pump inhibitors may be effective

• Maintenance of remission:
  • stop smoking
  • for patients withdrawing from steroids and relapsing more than once a year: azathioprine, mercaptopurine or methotrexate

• Chronic active and steroid dependent disease:
  • azathioprine, mercaptopurine or methotrexate

Surgery

Ulcerative colitis

• Surgery advisable if no response to intensive medical therapy

Crohn's disease

• Surgical intervention is determined by the extent of the disease, the response to medical treatment and the presence or absence of complications

Preventing postoperative recurrence

• Advise patient to stop smoking
• Consider adjuvent treatment post-surgery

Pouchitis

• Diagnosis: combination of clinical, endoscopic and histological criteria
• Metronidazole or ciprofloxacin initially, long-term if frequent relapses

Associated aspects of inflammatory bowel disease

• Pain:
  • treat underlying cause if possible
  • NSAIDs are not recommended for pain relief in IBD
  • opioid, e.g. tramadol, for non-specific pain

• Fatigue:
  • identifiable cause of fatigue in the absence of active disease is not yet known
  • exclude anaemia and sub-therapeutic maintenance medication doses

• Surveillance for colonic carcinoma:
  • inform patient of risks and benefits and decide together whether surveillance is appropriate

• Pregnancy:
  • plan conception during remission
  • a gastroenterologist and obstetrician should manage pregnant women with IBD jointly
  • if acute severe colitis/life-threatening complications manage as if no pregnancy
  • methotrexate is absolutely contraindicated

• Nutrition:
  • regular assessment of nutritional status is essential in Crohn's disease
  • validated tools such as the British Association for Parental & Enteral Nutrition's Malnutrition Universal Screening Tool may be of help
  • nutritional support may be appropriate

• Extraintestinal manifestations:
  • usually respond to IBD therapy if associated with active disease, but follow their own course when disease is not active
  • patients with acute ocular manifestations should be referred for ophthalmological assessment before starting therapy

• Osteoporosis and osteomalacia are common. See Guidelines for osteoporosis in coeliac disease and inflammatory bowel syndrome

• Anaemia:
  • causes include: iron deficiency, anaemia of chronic disease, folate and vitamin B₁₂ deficiency, and drug-induced (azathioprine, mercaptopurine, sulfasalazine)
    
  • haemoglobin checks at least annually
    
  • replacement therapy with iron, vitamin B₁₂, or folate may be needed

• Vaccinations:
• offer primary and booster vaccination for influenza and pneumococcus to immunosuppressed patients with IBD
• consider human papillomavirus vaccination for female patients
• consider hepatitis B vaccination prior to immunosuppressive or anti-TNF monoclonal antibody therapy in the non-immune high-risk patient
• avoid live vaccines (e.g. MMR, oral polio, yellow fever, live typhoid, varicella, BCG) for patients on immunosuppressant therapy or steroids

• Psychological:
• psychological support should be available to patients with IBD

full guidelines available from…
British Society of Gastroenterology, 3 St. Andrew's Place, Regent's Park, London NW1 4LB (Tel – 020 7935 2815)
http://www.bsg.org.uk/

Mowat C, Cole A, Windsor A et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2011; 60 (5): 571–607.