Treating IBD: Choosing an appropriate therapy

Crohn’s disease and ulcerative colitis are both inflammatory diseases of the bowel and, thus, overlap with respect to clinical findings, epidemiology, and pathology. However, therapy that is appropriate for treating one condition may not be appropriate for treating the other, said Lynn Patton, R.Ph., M.S., associate professor and vice chair, department of pharmacy practice, Chicago College of Pharmacy, Midwestern University. Patton is also pharmacy clinical specialist, Nutrition Consult Service, Rush-Presbyterian-St. Luke’s Medical Center.

Conventional therapies for these conditions are sometimes ineffective, and patients may turn to complementary and alternative medicine (CAM), added Ali Keshavarzian, M.D., professor of medicine and professor of pharmacology, molecular biophysics, and physiology, Rush Medical College. Although CAM therapies can be efficacious, they may also have serious consequences. Issues regarding CAM treatments for inflammatory bowel disease (IBD) were discussed at a symposium presented during the recent Nutrition Week conference in San Diego.

Patton explained that there are differences between Crohn’s disease and ulcerative colitis. Crohn’s disease is characterized by constant pain, which is often localized to the lower right quadrant. This pain is not relieved by defecation. Patients with Crohn’s disease do not have grossly bloody stools. Crohn’s disease can affect any area of the gastrointestinal tract, and is usually discontinuous, with affected areas alternating with unaffected areas. This condition is transmural, because it can affect the mucosa, submucosa, and muscular wall of the GI tract.

Ulcerative colitis is characterized by crampy lower abdominal pain that is relieved by defecation, Patton continued. Those with this condition have chronic, bloody diarrhea. Ulcerative colitis affects only the mucosal lining of the colon and is continuous from the rectum upward.

Therapies that are efficacious in treating one inflammatory bowel disease may not be efficacious in treating the other condition, because of these differences. For this reason, Patton said, "Patients must receive the appropriate drug for the area of the GI tract affected." Among the examples she gave was the 5-aminosalicylate drug sulfasalazine. Sulfasalazine is indicated for ulcerative colitis but not for Crohn’s disease, because it is cleaved into its components by colonic bacteria.

Patton feels that the future will bring more so-called high-tech or biotech drugs such as infliximab (Remicade, Centocor), which was first approved by the Food & Drug Administration in 1998. Last month, Centocor announced that infliximab would be granted priority review by the FDA as monotherapy for inducing and maintaining remission in those with moderately to severely active Crohn’s disease.

These conventional therapies may not achieve their goal of inducing and maintaining remission in all patients, warned Keshavarzian. When traditional drugs fail, clinicians and patients are driven to CAM therapies. The accepted definition of CAM therapies, he said, is medical interventions that are not in conformity with the standards of the medical community, not widely taught in North American medical schools, and not generally available in North American hospitals. Keshavarzian mentioned that this definition was originally developed by David Eisenberg of Harvard University.

According to Keshavarzian, one important difference between conventional Western medicine and CAM therapies is that CAM utilizes a holistic, as opposed to an allopathic, approach to care. CAM practitioners see disease as affecting the whole patient, not just a particular organ. They address multiple possible influences on a disease process, using multiple treatment modalities, including herbal remedies, acupuncture, and massage.

Keshavarzian believes clinicians need to know about CAM because it is being used extensively worldwide. Recent studies, he stated, indicate that approximately 30%-60% of IBD patients use CAM. A majority of patients do not discuss their CAM use with their healthcare provider, however, because they fear the clinician’s disapproval. Unfortunately, he said, many CAM therapies use active biologic agents that may interact with allopathic agents and have adverse effects.

It is important to ask patients about CAM use in a nonjudgmental manner and to keep a record of CAM use. Patients should understand that just because a product is "natural" does not mean that it is safe. Keshavarzian said recent studies indicated that "probiotics" such as lactobacillus and intestinal helminth are beneficial for IBD patients. Also, fish oil and tumeric may help. Results of controlled studies are necessary, however, for the validation of these findings. Pharmacists can encourage patients to discuss their CAM use with their physician, in the same way that they would discuss other matters.

In addition to addressing the issue of CAM use, pharmacists can provide a private place to confer with patients. Patton felt that privacy is important because it can be a barrier to patients being more open in talking to their pharmacist. She also advised that pharmacists question closely patients taking immunosuppressive therapies. If these persons show signs of infectious disease, such as a fever or sore throat, they should be referred to a physician.

Charlotte LoBuono

Charlotte LoBuono. Treating IBD: Choosing an appropriate therapy.

Drug Topics

2002;10.