How should I treat IBD?
Pharmacological treatment options for Crohn's disease aim to reduce symptoms and maintain or improve quality of life while minimising toxicity related to drugs over the short and long term.
Pharmaceutical therapies include glucocorticosteroid treatment, antibiotics; immune suppressives, such as azathioprine* and mercaptopurine; and tumour necrosis factor-α inhibitors. Other therapeutic options include attention to nutrition, smoking cessation and, in severe or chronic active disease, surgery.1,2
Treatment options for ulcerative colitis focus on active disease and aim to address symptoms, improve quality of life, and maintain remission.
Treatment options for active disease depend on clinical severity, extent of disease, and patient preference. Pharmaceutical therapies include corticosteroids; 5-aminosalicylate treatment; immune suppressives, such as azathioprine* and mercaptopurine; or biological drugs. Surgery may be considered as emergency treatment for severe ulcerative colitis that does not respond to drug treatment, and in patients who wish to have elective surgery for unresponsive or frequently relapsing disease that is affecting their quality of life.2,3
In patients who have IBD and are still experiencing symptoms despite evidence suggesting treatment is working additional diagnoses such as: IBS, bile acid malabsorption, and lactose intolerance should be considered.
*TPMP (thiopurine s-methyltransferase) levels should be measured in all patients with a diagnosis of IBD in anticipation of the need to treat with azathioprineReferences
- National Institute for Health and Care Excellence. Crohn’s disease – Management in adults, children and young people (CG152). 2012. London: National Institute for Health and Care Excellence.
- Crohn’s and Colitis UK. Azathioprine and Mercaptopurine. Available from http://www.crohnsandcolitis.org.uk/Resources/CrohnsAndColitisUK/Documents/Publications/Drug-Info/Azathioprine%20and%20Mercaptopurine.pdf last accessed May 2015.
- National Institute for Health and Care Excellence. Ulcerative colitis – Management in adults, children and young people (CG166). 2013. London: National Institute for Health and Care Excellence.
How should I treat IBS?
NICE recommends that patients with IBS should be given information that explains the importance of self-help in effectively managing their IBS, including information on general lifestyle, physical activity, diet and symptom-targeted medication.
A 2-3 month trial of a low FODMAP (Fermentable, Oligo-saccharides, Di-saccharides, Mono-saccharides And Polyols) diet should be considered for patients with IBS.
Pharmacological options for IBS include laxatives or antimotility agents.
Tricyclic antidepressants should be considered as a second-line treatment if laxatives, loperamide or antispasmodics have not helped.1
Patients with predominant diarrhoea may have bile acid malabsorption. Patients should be referred for a SeHCAT scan and should be treated according to local protocols.2,3
A lactose elimination diet should also be considered due to the similarities between the symptoms of IBS and lactose intolerance.4References
- National Institute for Health and Care Excellence. Irritable bowel syndrome in adults – Diagnosis and management of irritable bowel syndrome in primary care (CG61). 2008. London: National Institute for Health and Care Excellence.
- University Hospitals Coventry and Warwickshire. What is BAM? Available from: http://www.uhcw.nhs.uk/bam/what-is-bam last accessed May 2015.
- National Institute for Health and Care Excellence SeHCAT (tauroselcholic [75 selenium] acid) for the investigation of diarrhoea due to bile acid malabsorption in people with diarrhoea-predominant irritable bowel syndrome (IBS-D) or Crohn's disease without ileal resection (DG7). 2012. London: National Institute for Health and Care Excellence.
- Lactose Intolerant. Available from http://www.lactoseintolerant.co.uk/diagnosing-lactose-intolerance/related-conditions/ibs last accessed May 2015.
How should I treat coeliac disease?
Implementing a gluten-free diet
In coeliac disease it is important for patients to adhere to a gluten-free diet, regardless of if they are symptomatic or not. Many people with coeliac disease either never experience symptoms or do not acknowledge them. However, because of long-term complications it is important that all patients with coeliac disease eat a gluten-free diet, even when there are no symptoms.1
When implementing a gluten-free diet it is important to remember that some patients are more sensitive to gluten than others. These patients may require a more stringent diet. It is also important to remember that the diet will also need to be balanced, nutritious, and varied.
A gluten-free diet should exclude:
ITEMS CONTAINING MALT
*Foods cooked with a bread-based batter
**Patients with well controlled coeliac disease can eat products that contain pure, uncontaminated oats. However, if the oats seem to cause symptoms, they should be removed from the diet and specialist advice sought
***Items fried in the same oil as used to fry gluten-containing food, i.e chips from a chip shop that cooks battered fish
NICE recommends that following diagnosis, people with coeliac disease should initially be followed-up in secondary care until they are progressing satisfactorily on a gluten-free diet. However, while waiting for a secondary care appointment, your patient should be provided with advice on starting a gluten-free diet.1 Coeliac UK contains excellent patient advice.
You should always advise your patients to check food labels carefully.
- National Institute for Health and Care Excellence. Coeliac Disease – Recognition and assessment of coeliac disease (CG86). 2009. London: National Institute for Health and Care Excellence.