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home - IBD - Treatment - UC Treatment Algorithm 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 Algorithm

Left sided colitis and Extensive ColitisHave a lower threshold for systemic steroids. 1. -Correct electrolytes2. -Sigmoidoscopy or proctos-opy and biopsy to confirm the diagnosis and exclude CMV3. -Stool cultures and assay for C.diff 4. -S/c heparin to reduce the risk of thromboembolism5. -Enteral nutrition rather than TPN6. -Withdrawal of anticholiner-gic, antidiarrhoeal agents, NSAID and opioid drugs.7. -Topical therapy (corticosteroids or mesalazine) if tolerated and retained but benefit not clear8. -Antibiotics only if infection is considered9. Maintain a Hb >10 g/dl Early relapse Any patient who has an early (<3 months) relapse is best started on (AZA) or 6-MP, Re-evaluation not necessary unless causes change in managementContinued medical therapy that does not achieve steroid-free remission is not recommended‘Steroid-dependent’, active ulcerative colitis Azathioprine can induce remission in 53% after 6 months/AZA should be the first choice of therapy in apparent steroid dependence.26% get steroid free remission after 1 year with infliximabOral steroid-refractory ulcerative colitis Consider other reasons for being refractory eg CMV/ non-adherenceConsider surgeryImmunomodulator-refractory ulcerative colitis Consider infliximab or colectomy Treatment of UC Mild to moderate ulcerative proctitis or proctosigmoiditis Either: 5-ASA/ steroid suppository with rectal enema or foam bdOr:Oral 5-ASA Do both above together Oral steroids No response No response Mild to moderate left sided UC Combined oral 5-ASA with suppository and foam Oral steroids Azathioprine Infliximab Failure of mild or moderately active disease to respond within 2 weeks to mesalazine is an indication to consider oral prednisolone. IV steroids for 5-7 days (beyond 7 days no benefit) Oral steroids with rectal supps and foam and oral 5-ASA -Ciclosporin monotherapy (CsA, 4mg/kg/day intravenously) is as effective as iv methylpredn-solone (MeP) 40 mg/ day for acute severe colitis-In a randomized trial there was a response in 10/15 CsA patients vs 8/15 MeP patients-Furthermore, half of all patients in another study comparing low dose with high dose CsA50 also received CsA monotherapy, without concomitant intravenous steroids-Consequently monotherapy with CsA is a useful option in those patients with severe colitis when steroids are best avoided Tapering steroids and azathioprine iv cyclosporin or infliximab or colectomy Severity criteria Temp >37.8C Hb<10.5g/dl ESR more than 30mm Pulse more than 90 bpm Stool frequency > 6 per day Severe proctitis, proctosig-moiditis or left sided colitis Colectomy (29% colectomy rate) Treatment according to the course or behaviour of disease Written by Dr Sebastian Zeki

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