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home - IBD - Treatment - Crohns Treatment Written by Dr Sebastian Zeki
Knowledge

Knows the criteria for assessing the severity and extent of IBD, in
particular recognition of acute severe colitis. Knows treatment options
including aminosalicylates, corticosteroids, and steroid sparing
therapies.

Knows differing methods of delivery for therapy.
Skills
Selects of appropriate treatment for extent and severity of disease,
including timing of immunomodulator therapy and referral for surgery.

Behaviours
Recognises the urgency of treating acutely sick patients, including
multidisciplinary team early, particularly surgeons. Clearly explains
the clinical situation and treatment options to patient and family.
Involves patient and family in decision making about treatment
options.

also....
Knows the complications of IBD including stricturing, fistulae,
extraintestinal manifestations, colon cancer and special situations
such as pregnancy.

Skills
Able to recognise potential complications and take appropriate action
to investigate and alter treatment as necessary including referral for
surgery and involvement of other healthcare professionals

Behaviours
Works with patient to explain complications and options for treatment
Involves the multidisciplinary team especially IBD nurse and surgeon
in management, and tailors treatment to the needs of the patient.
Discusses with colleagues early and appropriately

Also...

Knowledge


Understands the importance of multidisciplinary decision making
including when radiological histopathological and surgical opinions
should be sought



Understands the role of the IBD nurse within the MDT and in
communicating with patients and their relatives

Recognises the importance of other healthcare professionals in
providing high quality care including dieticians and pharmacists

Aware of the surgical options available in IBD and how to access
them

Skills
Has appropriate discussions with other specialties including
surgeons and other healthcare professionals

Can participate in an IBD MDT effectively
Relates well with all other healthcare professionals involved in IBD
patient care especially the IBD Nurse Specialist

Behaviours
Shows commitment to team-working and shows understanding of the
roles of other healthcare professionals with courtesy

Explains decision making process to the patient clearly and
sympathetically

Also...

Knowledge

Knows the different treatment modalities for IBD given the disease
extent activity previous history and complications

Knows the modes of delivery of different drug therapies and their
advantages and disadvantages

Recognises the importance of patient choice in deciding therapy and
in helping to ensure adherence

Understands when surgery is the most appropriate therapeutic option
and to make appropriate referrals

Skills
Demonstrates the ability to identify the possible range of appropriate
treatments for a particular patient and have an appropriate discussion
allowing the patient and doctors to come to a sensible consensus

Behaviours
Effectively communicates the possible treatment options and the
potential benefits complications and side effects of each

Also...

Knowledge


Knows the effect of active IBD drug therapy and surgery on fecundity
and pregnancy specifically issues relating to immune suppressants
biological therapy and surgery

Knows the effect of IBD and its treatment on breast feeding
Knows the effects of the disease and its treatment on the chances of
conception for men with IBD

Skills
Appreciates when to alter treatment to take account of pregnancy and
breast feeding

Can provide accurate advice about the effect of disease treatment
and surgery on fecundity pregnancy and lactation

Behaviours
Can discuss in an appropriate manner the treatment options for
patients wishing to conceive who are already pregnant or who wish
to breast feed

Explains the issues relating to treatment to those patients and their
partners who are planning to conceive so as to enable them to make
informed choices


Also...




Knowledge


Knows the risks relating to a previous history of malignancy or the
development of malignancy in IBD in particular to understand how
this affects treatment options

Knows the risks relating to infection with hepatitis B hepatitis C and
HIV connected with treatment of IBD

Knows the circumstances in which patients should be screened or
immunised for infectious diseases before commencing therapy

Skills
Can identify patients at risk for particular treatment due to concurrent
or pervious medical conditions

Can identify patients who need to be screened or immunised for
infectious diseases prior to therapy

Understands the treatment options available for patients with preexisting medical conditions

Behaviours
Can explain to patients the reasons for screening /immunising
Can explain the way that treatment may be affected by other medical
conditions and to start appropriate treatment

Crohns Treatment

Mesalazine (mild only) stop smoking Metro/Ciproflox Budesonide Mesalazine (stop if no relapse more than one year) Azathioprine Metronidazole Azathioprine (halves risk of relapse 4-5 year treatment) Infliximab (0, 2, 6 weeks 5mg/kg as long as elemental diet Methotrexate (40% respond if steroid refractory. Parenteral is better) Steroids (NNT=2) - IV for five days the po) Infliximab Methotrexate Infliximab Drug Induction ofRemission Maintenance of Remission Azathioprine 50% @ 12m Methotrexate Adalimumab: Budesonide Certalizumab Infliximab Steroids Colitis Ileitis/ small bowel disease Ileocolitis Sulfasalazine 4 g/d for active colonic disease5 ASA-s may be good for L sided diseaseBudesonide only good for proximal colonic disease (with or without ileal involvement)Metronidazole can induce remission can be used as steroid sparingNutritional therapy may be less effective in colonic than small bowel disease in adults. Early introduction of immunomodula-tors with nutritional support.IFX for inflammationy while surgery for strictures Budesonide is somewhat less effective than prednisolone5-ASA not recommended for mildly active ileal CDAntibiotics (metronidazole, ciprofloxacin), +/- 5-ASA, or nutritional therapy are not recommended for mildly active CD in adults Moderately active localised ileocaecal CD Severely active localised ileocaecal CD Lower threshold for surgery for ileocaecal diseaseConsider surgery if medical tx is ineffectiv after 2-6wksAddition of ciprofloxacin and metronidazole to budesonide not useful. Oral pred for moderately active Crohn’s 92% Site specific Treatment Average timeto induction Median response time-2wks; median response duration-12 wks 54 week course: Remission 28% vs 14%; Response: 36% vs 15% (10% more if dose doubled) Single shot 5mg/kg: 4 weeks: 81% responseFistula response: 68% vs 26% for placeboFor fistulas: Closure: 55% vs 13% placebo No head to head but from trials adalimimab slightly better than infliximab at induction but similar at 56wkCertilizumab slightly better at 56wksAdded immunomodulators increases remission rates 4 week response: 36% vs 12% Corticosteroids in Crohn’sAdverse effects of corticosteroidsOsteoprotection if >12 weeks steroidsMore effective at induction than 4g/d mesalamine.Less effective than steroids po but less side effects Indication: Mild to moderate ileocaecal Crohn's Treat osteoporosis risk as being similar to steroidsPatients can still get Addison’s Efficacy of thiopurines 6-MP marginally >AZASafe length of time on treatment is unknown 83% 40% Less osteoporosis with budesonide vs predLower side effect frequency than pred (33% v 55%,6) and less severeRemission in 51%–60% over 8–10 weeks 65% In infliximab failures:4 week induction of remission in infliximab failures:: 21%. Stricturing InfliximabSurgical resectionBallooningStricturoplasty Over 56wks: 48% (vs 17% placebo) Withdrawal of long term med=Higher relapse risk (relapse happens after at least 18m in 80%) 79% 48% at 26 weeks Crohn’s Treatment Grading of disease activity in Crohn’s Mild Moderate Severe Equivalent to a CDAI of 150-220 Equivalent to a CDAI of 220-450 Equivalent to a CDAI of >450 Written by Dr Sebastian Zeki Acute Mild to Moderate Severe Maintenance Fistulating

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