Medications and tests Robert Dennis Consultant Colorectal Surgeon

Medications and tests Robert Dennis Consultant Colorectal Surgeon (Clinical Lead, General Surgery)

Medications – why? l l Medications cannot cure IBD but aim to control inflammation. This improves symptoms, reduces damage to the bowel and reduces the risk of complications Any medication is a balance between the risks of the medication (side effects) and the quality of life/ risks of not treating the IBD

Medications – how? l l Regularly at the prescribed dose Read patient information Ø Crohn’s and Colitis UK Ø https: //www. crohnsandcolitis. org. uk/aboutinflammatory-bowel-disease/treatments Discuss with IBD team Inform IBD team of any changes

Medications – what? l Types of medications: Ø Steroids Ø 5 aminosalicylates Ø ‘Immune modulators’ – Azathioprine, Methotrexate & Mercaptopurine Ø ‘Biological therapy’ – Infliximab, Adalimumab, Vedolizumab

Medications – steroids l l l Synthetic versions of the body’s own steroid hormones Glucocorticoids are steroids used in IBD Powerful and effective at settling active inflammation in most ‘flares’ of IBD Potentially significant side effects Ø https: //www. crohnsandcolitis. org. uk/aboutinflammatory-bowel-disease/ publications/steroids Aim is for minimal short term courses Ø More than 2 courses in 12 months – review medication regimen

Medications – 5 aminosalicylates l l l Anti-inflammatory drugs Used to help treat flares and then maintain remission (preventing further flares) Generally well tolerated without major side effects Rare but serious side effect of damage to blood making cells Ø Unexplained bruising, bleeding or high temperatures Kidney function monitoring Blood tests 2 -3 months after starting and then every 6 months – Kidney function (+/- Full blood count)

Medications – 5 aminosalicylates l Patients altering the dose: Ø Yes Ø Important to continue even when feeling well Ø Inform IBD team Ø Proctitis l Ø Colitis l Ø Start suppositories or foam enemas if any rectal bleeding Increase oral ASA dose to acute treatment dose (2 – 2. 4 g twice daily) for 12 weeks Blood tests – FBC, U&E, CRP, LFT

Medications – immune modulators l l l Medications which partially suppress the body’s immune system to reduce the inflammatory response Azathioprine, Methotrexate, Mercaptopurine Potentially greater risk with these medications Ø Increased risk of infections Ø Risks of other side effects Ø Regular blood tests l Weekly for first 8 weeks, then monthly for 3 months, then every 3 months

Medications – immune modulators l l l Often used in combination with other medications to reduce the dose and risks Important to take regularly Important to read patient information

Medications – biological therapy l l Synthetic antibodies (complex molecules the body normally produces to help destroy infections) Antibodies created to block specific molecules in the immune response – ‘TNF’ Newer medications Generally well tolerated and safe

Tests l Wide range of tests used in managing IBD: Ø Endoscopy Ø Blood tests Ø Faeces tests Ø Scans

Tests l l l Provide information as part of the overall picture Benefits: Ø Information about the level of inflammation Ø Information about any damage to the bowel eg narrowings Ø Colon surveillance if risk of cancer (6 -8 yrs after diagnosis of pan colitis) Risks: Ø Direct complication of the procedure Ø False negative - test fails to detect problem Ø False positive - test appears to show a problem which is not actually there

Tests - Endoscopy l l l Fibre optic camera to examine the lining of the bowel ‘Gold standard’ test allowing direct visualisation of the bowel, samples to be taken (biopsies) and potentially treatments eg stretching narrowings All patients with IBD will need endoscopies Ø Frequency and what types very variable

Tests - Endoscopy l l l ‘OGD’ or ‘gastroscopy’ – camera passed by the mouth Flexible sigmoidoscopy or colonoscopy – camera passed via the anus Bowel prep: Ø Ø Ø Follow instructions – do it right first time! Cold Use a straw Gummy bears – count as clear liquid Barrier creams – Vaseline, Sudocrem, Metonium

Tests – Blood tests l l l Help monitor levels of inflammation in the body Help monitor for side effects of medications Help planning starting new medication Not specific to IBD Inflammation blood tests: Ø White Cell Count Ø CRP Ø ESR

Tests – Faeces tests l l Tests for infection Faecal Calprotectin – tests for levels of inflammation Ø Diagnosis of a flare Ø Monitoring of treatment

Scans l Wide range of scans can be done: Ø Ø l l CT scans – ‘donut’ scanner, quick, x-rays MRI scan – tunnel, noisy and slow, magnet Ultrasound – ‘jelly’ scan, commonly used in pregnancy Barium x-rays – following a liquid which is drunk through the intestine with x-rays Used to assess the small bowel which cannot reach with endoscopy Used to look outside the bowel for other problems or complications of IBD such as perforation/ fistula

Medications and tests Drugs to avoid: l Non steroidal anti-inflammatories Ø Ibuprofen Ø Naproxen l Anti-diarrhoeal medications Ø Can mask symptoms of flare Ø Check with IBD team/ surgeon Ø Rarely appropriate to be taken regularly

Medications and tests l l l Home remedies – such as Manuka honey, Aloe Vera Oil Fine to use Do Seton stitches need to be replaced? Only if they fall out Medical exemption of prescription charges if you have a stoma Yes (if permanent, but any stoma can be permanent) Stoma nurses can advise

Medications and tests l Prepaid prescription charges Ø https: //www. gov. uk/get-a-ppc