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home - IBD - Treatment - UC 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

UC Treatment

Rectal ASA- maintain remission in 70% 29% Overall remission rates on aza= 87%. Median time to relapse after stopping = 18 months 41.2% For 4.8g MMX20.2% for 4.8g asacol Clinical remission by 8 weeks in 64% 67% or77% for oral steroids in mild-moderate Sulphasalazine may be a bit better at maintain-ing remission than 5-ASANo further improvement with doses > 0.8 g/day 10 % 80% Response Rate 65% relapsed within 1 year, and 90% within 3 years. 88% at 7 years if CsA added + already on AZA Colectomy rate if already on AZA vs starting AZA concurrently with CsA was 59% vs 31%, respectively (treated with ciclosporin during acute flare) Steroid free remission rate at 1 year is 25% Overall remission- 35%If IFX as rescue for steroid resistant acute UC+ aza naive, there is a role for adding aza- 2 year f/u gives colectomy free rate of 85% vs 50% (no AZA).If giving IFX and azathioprine, can stop aza after 6 mm with no loss of response to IFX over 2 years. As rescue treatment, reponse is 25 -75% 70% within 2 weeks. Better than topical steroids. Also better than oral mesalazine for proctitis Rectal 5-ASA sl. better than oral mesalazine in distal UC- >1 g/day PR unneccessary The combination of oral mesalazine and intermittent rectal 5-ASA appears to provide further benefit above rectal or oral alone For steroid dependent patients, Steroid-free, clinical and endoscopic remission was achieved in 53% on AZA, compared to 21% given 5-ASA On azathioprine: (26%) underwent colectomy vs 81% who did not receive AZA maintenance. 88% came to colectomy over 7 years Drug Induction ofRemission Maintenance of Remission Failure Infliximab in Ulcerative ColitisACT 1- UC treated with steroids/ 6-MP/ AZA ACT2- Refractory UCClinical response @ 8, 30 and 54 weeks: better response than placebo if not refactoryClinical remission: Better in infliximab group- in ACT I- 34% and ACT II- 30%Endoscopic Healing: ACT I- 55% Other TreatmentsE.coli strain Nissle 1917 is not inferior to the established standard 5-ASA for maintenance of remission in UCAdalimumab, certolizumab,etanercept, natalizumab, visulizumab, interleuki fontolizumab (an anti-interferon γ antibody), basiliximab, daclizumab, alicaforsen (an anti-ICAM1 antisense molecule), anti-IL12 and anti-IL6 antibodies have not yet been evaluated for mainte-nance of remission in UC, and nor have leucocytapheresis, tacrolimus, or cyclophosphamide in any meaningful wayMetronidazole is slightly more effective than sulphasalazine at 1 year. Ciprofloxacin is not. Antibiotics are not recommended treatmentsMethotrexate data not great. More patients achieve and stay in remission on aza. May have a role in aza intolerant patientsNo benefit in omega-3- fatty acid treated patients Tacrolimus (No proven role in UC ) Infliximab iv ciclosporin in azathio-prine resistant patients Azathioprine after iv ciclop-orinn induced remission iv Ciclosporin. Also applies to tacrolimus Rectal and Oral mesalazine Oral mesalazine Rectal mesalazine Steroids (for severe acute) Azathioprine Drug Treatment of ulcerative colitis Written by Dr Sebastian Zeki

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