Inflammatory bowel disease (IBD) refers to relapsing or continuous inflammatory diseases of the intestine. Crohn’s disease and ulcerative colitis belong to this group of forms. “Don’t be afraid of guidelines,” was a key message from gastroenterologist Ingo Mecklenburg, MD, of University Hospital Basel, at the SGIM workshop on the therapy of IBD. The therapeutic goal is not only symptom relief, but complete control of the disease with histologic remission.
In Switzerland, around 15,000 people suffer from inflammatory bowel disease (IBD). In addition to a genetic predisposition, environmental factors are also discussed for the development of the diseases. Thus, smoking increases the risk for developing Crohn’s disease and also for a recurrence of the disease. “Characteristics of both diseases include (sometimes bloody) diarrhea and abdominal pain,” Ingo Mecklenburg, MD, elaborated at the SGIM congress. The occurrence of extraintestinal manifestations in the sense of arthritides, skin changes and eye inflammations are also possible.
A variety of complications can occur during the course of IBD, which is why early and sustained disease control is necessary. Patients with inflammatory bowel disease are relatively young, resulting in a high secondary cost of illness. Extrapolated data suggest an economic loss of more than CHF 300 million per year in Switzerland due to treatment, work loss and retirement as a result of IBD. Since ulcerative colitis and Crohn’s disease show very different inter- and intraindividual courses, risk stratification and risk-adapted therapy are used. Risk factors for a complicated course in Crohn’s disease include protracted inflammation, patient age less than 40 years, nicotine use, perianal disease, upper gastrointestinal tract manifestation, extraintestinal manifestations, and protracted steroid use. “Every relapse in Crohn’s disease leads to further structural disorders and should be treated early and without voodoo,” the expert said. Disease control with mucosal healing and histological remission (deep remission) is now considered the primary therapeutic goal.
Diagnostics and course
Diagnosis of IBD is made by endoscopy and biopsy. In Crohn’s disease, endoscopic images of the colon and ileum show mucosal lesions and patchy redness even in the early stages. An episode may manifest with ulcerations, fissures, or fistulas. Stenoses are often a late consequence of uncontrolled inflammation. The localization as well as the endoscopic and pathological findings lead to the diagnosis. “Indeterminate colitis has become a rarity in our country when diagnosed according to the rules; in almost all cases, a definite diagnosis can be made at the latest during the course,” Dr. Mecklenburg emphasized. And very important: Every Crohn’s patient should also undergo a gastroscopy, as the stomach and duodenum may also be affected.
The determination of calprotectin in stool is a relatively reliable and thus suitable non-invasive method for monitoring the course of IBD [1]. Calprotectin is a cytoplasmic protein of leukocytes that is particularly resistant to enzymatic degradation in the intestinal lumen. Thus, fecal calprotectin detects the extent of granulocyte infiltration into the intestinal lumen, and the magnitude of the readings correlates with the severity of the disease. “Consequently, fecal calprotectin measurement represents an objective marker for assessing inflammatory activity in IBD,” Dr. Mecklenburg elaborated.
Figures on disease progression over ten years were provided by Solberg et al. [2] in a large cohort in Norway: 43% relapsing-remitting symptom recurrence, 19% chronic persistent symptoms, 32% chronic recurrent symptoms, and 3% increasing symptom intensity. The course of the disease is unpredictable and varies greatly from individual to individual. The acute relapsing form of the course is reflected in individual acute relapses that can last for weeks and are interrupted by remission phases lasting from weeks to years.
Disease control target
Guideline-based therapy can control not only the symptoms but the disease per se (mucosa healing, histologic remission, and normalization of quality of life). “We have effective drug classics and some hopefuls in the pipeline,” Dr. Mecklenburg said optimistically. Although data show that about one-third of patients also respond to placebo therapies, sustained remission is achieved by only a few. The therapy of IBD is presented in a transparent and practical way in the guidelines of the DGVS [3, 4] and the European Crohn’s and Colitis Organization ECCO [5].
In ulcerative colitis, he said, mesalazine is still the first choice. “I don’t really see any contraindications for its use,” the expert said. A major advance, he said, are the sustained-release preparations with a release of the ingredients in the colon. They only need to be taken once a day (Salofalk®, Pentasa®). In proctitis, patients would often be inhibited from using suppositories, enemas or foam preparations at the beginning. However, Dr. Mecklenburg emphasized that if patients had overcome their shyness, the efficacy would convince them. “In acute relapse, oral and topical mesalazine remains the most effective medication for mild to moderately severe ulcerative colitis.”
In Crohn’s disease, however, no efficacy for mesalazine was supported by data. Therefore, it is only used in individual cases. In Crohn’s ileitis, budesonide (Budenofalk®) has been established for induction and maintenance therapy under close clinical supervision.
Take Home Message
- IBD shows an undulating course, making it difficult to assess prognosis.
- There is no standard therapy.
- The therapeutic goal is steroid-free remission with healing of the mucosal lesions.
- Risk factors suggest a more complicated course in a subgroup of patients.
- Patients at high risk benefit from early immunosuppressive therapy.
- Any immunosuppressive therapy may also induce adverse effects, but the clinical benefit far outweighs any adverse effects.
Source: Inflammatory Bowel Disease Workshop at the 81st Annual Meeting of the SGIM, May 29-31, 2013, Basel, Switzerland.
Literature:
- Schoepfer AM et al: Fecal calprotectin correlates closely with the simple endoscopic score for Crohn’s disease (SES-CD) than CRP, blood leukocytes and the CDAI (Chron’s disease activity index). Am J Gastroenterol 2010; 105: 162-169.
- Solberg IC et al: Clinical course in Crohn’s disease: results of a Norwegian population-based ten-year follow-up study. Clin Gastroenterol Hepatol 2007 Dec; 5(12): 1430-1438.
- Dignass A. et al: S3 Guideline “Diagnosis and Therapy of Ulcerative Colitis” 2011. www.dgvs.de.
- Hoffmann J. C. et al: S3-Leitlinie “Diagnostik und Therapie des Morbus Crohn” 2008. www.dgvs.de.
- www.ecco-ibd.eu.
