Patient Patient Self Management Self Management

ProgrammeProgramme

Dr. Matt. JohnsonDr. Matt. Johnson

Congratulations !!Congratulations !!

•You’ve just graduated You’ve just graduated throughthrough

The School of IBDThe School of IBD

Patient Self ManagementPatient Self Management

• 1) Relatively Stable Disease1) Relatively Stable Disease• 2) Relatively Sensible Patients2) Relatively Sensible Patients

• All doctors differ in their managementAll doctors differ in their management• National guidelinesNational guidelines

– BSG guidelinesBSG guidelines– ECCO guidelinesECCO guidelines– AGA guidelines AGA guidelines

What does it all mean?What does it all mean?

• We finally get rid of youWe finally get rid of you

• But this doesn’t mean your forgottenBut this doesn’t mean your forgotten– Telephone accessTelephone access– Access to medical informationAccess to medical information– Access to emergency clinicsAccess to emergency clinics– Full screening following National Full screening following National

StandardsStandards

Aims of TreatmentAims of Treatment

• 1) Symptom control1) Symptom control• 2) Disease control 2) Disease control (bloods, calprotectin)(bloods, calprotectin)

• 3) Avoid Medical Complications 3) Avoid Medical Complications (steroids, DEXA)(steroids, DEXA)

• 4) Avoidance of Surgery and its Complications4) Avoidance of Surgery and its Complications• 5) Reduce cancer risk 5) Reduce cancer risk (mesalazine = 50%, (mesalazine = 50%,

colonoscopy)colonoscopy)

• Guidance through pregnancyGuidance through pregnancy

Aims of TreatmentAims of Treatment

• 1) Symptom control1) Symptom control

For UC Patients = UCDAIFor UC Patients = UCDAI

• 1) Daily stool frequency = • Usual post operative frequency 0• 1–2 stools more than usual per day 1• 3-4 stools more than usual per day 2• > 4 stools more than usual per day 3• 2) Rectal Bleeding• None 0• Streaks of blood 1• Obvious blood 2• Mostly blood 3• 3) General well being• Generally well 0• Slightly unwell 1• Moderately unwell 2• Very unwell 3

• Remission = ≤ 2 / 9

For Crohns’ Patients = For Crohns’ Patients = Harvey Bradshaw ScoreHarvey Bradshaw Score

• Number of liquid Stools No.• Abdominal pain None 0• Mild 1• Moderate 2• Severe 3• Abdominal mass None 0• Dubious 1• Definite 2• Definite and tender 3• General wellbeing Very well 0• Slightly below par 1• Poor 2• Very poorly 3• Terrible 4• Number of EGIMOF IBD 1 point each• Mouth ulcers, uveitis, arthralgia• Anal fissure, new fistular, perianal abscess• Erythema nodosum, pyoderma gangerenosum

• Remission = ≤ 5

Extra GI Manifestations of Extra GI Manifestations of IBDIBDEffects approx 4%, may include:Effects approx 4%, may include:

• Erythema Erythema nodosumnodosum • AphthousAphthous ulcers ulcers • UveitisUveitis, episcleritis, episcleritis • Acute arthropathy affecting the large joints Acute arthropathy affecting the large joints

(e.g. wrists, hips, knees)(e.g. wrists, hips, knees) • SacroiliitisSacroiliitis • Pyoderma gangrenosumPyoderma gangrenosum • Primary sclerosing cholangitisPrimary sclerosing cholangitis • Ankylosing spondylitisAnkylosing spondylitis

Distal colitis + Proximal Distal colitis + Proximal ConstipationConstipation

Distal colitis + Proximal Distal colitis + Proximal ConstipationConstipation

Aims of TreatmentAims of Treatment

• 2) Disease control 2) Disease control (bloods, calprotectin)(bloods, calprotectin)

Quiescent UC Acute UCQuiescent UC Acute UC

Patient ManagementPatient Management

CROHNSCROHNS

• AntibioticsAntibiotics• Elemental diet / TPNElemental diet / TPN• Budesonide / PrednisoloneBudesonide / Prednisolone• ?? (Pentasa – mesalazine)?? (Pentasa – mesalazine)• Azathioprine (2.5mg/kg/d)Azathioprine (2.5mg/kg/d)• Pre/ProbioticsPre/Probiotics• Methotrexate (15-25mg / w)Methotrexate (15-25mg / w)

• Infliximab (anti TNF 5mg /kg) Infliximab (anti TNF 5mg /kg)

• Surgery (palliative)Surgery (palliative)

UCUC

• PO MesalazinePO Mesalazine• PO PrednisolonePO Prednisolone• PR Mesalazine / SteroidPR Mesalazine / Steroid• PO Azathioprine (2.5mg/kg)PO Azathioprine (2.5mg/kg)• PO Pre/ProbioticsPO Pre/Probiotics• IV HeparinIV Heparin• IV Cyclosporin (3-4mg/kg/d)IV Cyclosporin (3-4mg/kg/d)

• !! IV Infliximab (Acute UC)!! IV Infliximab (Acute UC)

• Surgery (curative)Surgery (curative)

Aims of TreatmentAims of Treatment

• 3) Avoid Medical Complications (steroids, 3) Avoid Medical Complications (steroids, DEXA)DEXA)

Monitoring of Medical Monitoring of Medical ComplicationsComplications

• Mesalazine NephritisMesalazine Nephritis

• Haematinic deficiencies Haematinic deficiencies – (Fe, B12, Folate, VitD) (Fe, B12, Folate, VitD)

• Steroid Induced Osteoporosis Steroid Induced Osteoporosis (BSG (BSG guidelines)guidelines)

– OsteopeniaOsteopenia 35%35%– OsteoporosisOsteoporosis 15%15%

• Azathioprine SEx Azathioprine SEx (FBC, U+Es, LFTs, TFTs, (FBC, U+Es, LFTs, TFTs, amylase)amylase)

Aims of TreatmentAims of Treatment

• 4) Avoidance of Surgery and its 4) Avoidance of Surgery and its ComplicationsComplications

Acute Crohns’ Stricture / Acute Crohns’ Stricture / FistulaFistula

• A Normal PouchA Normal Pouch

Aims of TreatmentAims of Treatment

• 5) Reduce cancer risk 5) Reduce cancer risk (mesalazine = 50%, (mesalazine = 50%, colonoscopy)colonoscopy)

Cancer SurveillanceCancer Surveillance

• Lifetime risk of IBD patient = 20%Lifetime risk of IBD patient = 20%

• Lifetime risk of gen pop = 15%Lifetime risk of gen pop = 15%

• Mesalazine reduces this risk by 50%Mesalazine reduces this risk by 50%

• Every 2 years to be started in those withEvery 2 years to be started in those with– Pan UC after Pan UC after = 8-10 years= 8-10 years– Distal UC after Distal UC after = 15 years= 15 years

Probiotics + Bowel Flora and Probiotics + Bowel Flora and IBDIBD• Crohn’sCrohn’s

– Low bifidobacteriaLow bifidobacteria– Low lactobacilliLow lactobacilli– High E.coli (in active) High E.coli (in active) 11

• UCUC– Low lactobacilli (in active) Low lactobacilli (in active) 22

• IBDIBD– High bacteriodes/toxins and E.coli (in active) High bacteriodes/toxins and E.coli (in active) 33

1.1. Giaffer M.H. et al. The assessment of faecal flora in patients with inflammatory bowel disease by a Giaffer M.H. et al. The assessment of faecal flora in patients with inflammatory bowel disease by a simplified bacteriological technique. Journal of Medical Microbiology 35: 5224-5231simplified bacteriological technique. Journal of Medical Microbiology 35: 5224-5231

2.2. Fabia R. et al. Impairment of bacterial flora in human UC and expeimental colitis in the rat. Fabia R. et al. Impairment of bacterial flora in human UC and expeimental colitis in the rat. Digestion 54: 248-243Digestion 54: 248-243

3.3. Swidsinski A. et al. Mucosal flora in inflammatory bowel disease. Gastroenterology 122: 44-54 Swidsinski A. et al. Mucosal flora in inflammatory bowel disease. Gastroenterology 122: 44-54

What’s on OfferWhat’s on OfferNameName StrainStrain ImplanImplan

ttUsesUses

Saccaromyces Saccaromyces boulardiiboulardii

YesYes DiarrhoeaDiarrhoea

Prevention + Prevention + RxRx

ActimelActimel L.casei strainL.casei strain DN-114001DN-114001

YesYes

Stoneyfield Stoneyfield YogurtYogurt

L.reiteriL.reiteri YesYes Diarrhoea RxDiarrhoea Rx

ArlaArla L.acidophilusL.acidophilus NCFB 1748NCFB 1748

YesYes

L.rhamnosusL.rhamnosus VTT E-97800VTT E-97800

YesYes

PrimaLivPrimaLiv L.rhamnosusL.rhamnosus 271271

YesYes

YakultYakult L.caseiL.casei strain strain Shirota Shirota

YesYes

CulturelleCulturelle L.caseiL.casei GG GG YesYes CDTCDT

Pro VivaPro Viva L.plantarumL.plantarum 299v299v

YesYes IBSIBS

Human Studies of Probiotics in Human Studies of Probiotics in UCUC• E. coli Nissle 1917 Vs Mesalazine 1y E. coli Nissle 1917 Vs Mesalazine 1y 1+21+2

• Remission = 68% Vs 73%Remission = 68% Vs 73%• Relapses = 67% Vs 73%Relapses = 67% Vs 73%

• LactobacillusLactobacillus• Sacchromyces boulardii + Mesalazine Sacchromyces boulardii + Mesalazine 33

• Aloe VeraAloe Vera• VSL#3 VSL#3 • Rembacken B.J. et al. Non-pathogenic E.coli verses mesalazine for the treatment of UC, a randomised trial. Lancet 354: 635-639Rembacken B.J. et al. Non-pathogenic E.coli verses mesalazine for the treatment of UC, a randomised trial. Lancet 354: 635-639• Kruis W. et al. Maintainance of remission in UC is equally effective with E.coli Nissle 1917 as with standard mesalazine. Kruis W. et al. Maintainance of remission in UC is equally effective with E.coli Nissle 1917 as with standard mesalazine.

Gastroenterology 120 Suppl. 1:A127 (Abstr. 680)Gastroenterology 120 Suppl. 1:A127 (Abstr. 680)• Guslandi M. et al. Saccharomyces boulardii in maintainance treatment of Crohn’s. Digestive Diseases and Sciences 45: 1462-Guslandi M. et al. Saccharomyces boulardii in maintainance treatment of Crohn’s. Digestive Diseases and Sciences 45: 1462-

14641464

Natural PrebioticsNatural Prebiotics

• Nutraceuticals = “functional foods” Nutraceuticals = “functional foods” • Inulin / Fructo-oligosaccharides / Lactulose Inulin / Fructo-oligosaccharides / Lactulose

Transgalacto-oilgosaccharidesTransgalacto-oilgosaccharides

• Chicory (boiled root = 90% inulin)Chicory (boiled root = 90% inulin)• Jerusalem artichokeJerusalem artichoke• Onion Onion • LeekLeek• GarlicGarlic• AsparagusAsparagus• BananaBanana• (cereals eg. Oatmeal)(cereals eg. Oatmeal)