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Management of inflammatory bowel disease

Emily K Wright, Nik S Ding and Ola Niewiadomski
Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01001
Published online: 1 October 2018

Summary

 

  • Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) in the world.
  • Early diagnosis and treatment for IBD is critical. For Crohn disease, in particular, this may change the natural history of disease and reduce disability.
  • Faecal calprotectin is a sensitive test that can be used by primary care physicians to assist in determining which patients with gastrointestinal symptoms may have IBD. This allows for prompt identification of patients who may benefit from endoscopy.
  • Regular re-evaluation of disease status with strategies that can safely, readily and reliably detect the presence of inflammation with faecal biomarkers and imaging is important. To avoid the risks of cumulative radiation exposure, magnetic resonance imaging and/or intestinal ultrasound, rather than computed tomography scanning, should be performed when possible.
  • Drug treatments for IBD now include five biological drugs listed by the Pharmaceutical Benefits Scheme: adalimumab, infliximab, golimumab, vedolizumab and ustekinumab. Such developments offer the possibility for improved disease control in selected patients.

 


  • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
  • 2 Box Hill Hospital, Melbourne, VIC


Correspondence: Emily.Wright@svha.org.au

Competing interests:

No relevant disclosures.

  • 1. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012; 142: 46-54.e42; quiz e30.
  • 2. Wilson J, Hair C, Knight R, et al. High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study. Inflamm Bowel Dis 2010; 16: 1550-1556.
  • 3. Niewiadomski O, Studd C, Hair C, et al. Prospective population-based cohort of inflammatory bowel disease in the biologics era: disease course and predictors of severity. J Gastroenterol Hepatol 2015; 30: 1346-1353.
  • 4. Ng SC, Tang W, Ching JY, et al. Incidence and phenotype of inflammatory bowel disease based on results from the Asia–Pacific Crohn’s and colitis epidemiology study. Gastroenterology 2013; 145: 158-165.e2.
  • 5. Jones J, Loftus EV Jr, Panaccione R, et al. Relationships between disease activity and serum and fecal biomarkers in patients with Crohn’s disease. Clin Gastroenterol Hepatol 2008; 6: 1218-1224.
  • 6. Pariente B, Cosnes J, Danese S, et al. Development of the Crohn’s disease digestive damage score, the Lemann score. Inflamm Bowel Dis 2011; 17: 1415-1422.
  • 7. Burisch J, Jess T, Martinato M, et al. The burden of inflammatory bowel disease in Europe. J Crohns Colitis 2013; 7: 322-337.
  • 8. Frolkis AD, Dykeman J, Negrón ME, et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145: 996-1006.
  • 9. Jostins L, Ripke S, Weersma RK, et al. Host-microbe interactions have shaped the genetic architecture of inflammatory bowel disease. Nature 2012; 491: 119-124.
  • 10. Gevers D, Kugathasan S, Denson LA, et al. The treatment-naive microbiome in new-onset Crohn’s disease. Cell Host Microbe 2014; 15: 382-392.
  • 11. Morgan XC, Tickle TL, Sokol H, et al. Dysfunction of the intestinal microbiome in inflammatory bowel disease and treatment. Genome Biol 2012; 13: R79.
  • 12. Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Am J Gastroenterol 2011; 106: 563-573.
  • 13. Schoepfer AM, Beglinger C, Straumann A, et al. Fecal calprotectin correlates more closely with the Simple Endoscopic Score for Crohn’s disease (SES-CD) than CRP, blood leukocytes, and the CDAI. Am J Gastroenterol 2010; 105: 162-169.
  • 14. van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ 2010; 341: c3369.
  • 15. Bryant RV, Friedman AB, Wright EK, et al. Gastrointestinal ultrasound in inflammatory bowel disease: an underused resource with potential paradigm-changing application. Gut 2018; 67: 973-985.
  • 16. Soetikno RM, Lin OS, Heidenreich PA, et al. Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis: a meta-analysis. Gastrointest Endosc 2002; 56: 48-54.
  • 17. Askling J, Dickman PW, Karlen P, et al. Family history as a risk factor for colorectal cancer in inflammatory bowel disease. Gastroenterology 2001; 120: 1356-1362.
  • 18. Rutter MD, Saunders BP, Wilkinson KH, et al. Cancer surveillance in longstanding ulcerative colitis: endoscopic appearances help predict cancer risk. Gut 2004; 53: 1813-1816.
  • 19. Sutherland L, Macdonald JK. Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2006; (2): CD000543.
  • 20. Sutherland L, Macdonald JK. Oral 5-aminosalicylic acid for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev 2006; (2): CD000544.
  • 21. James SL, Irving PM, Gearry RB, Gibson PR. Management of distal ulcerative colitis: frequently asked questions analysis. Intern Med J 2008; 38: 114-119.
  • 22. Ford AC, Kane SV, Khan KJ, et al. Efficacy of 5-aminosalicylates in Crohn’s disease: systematic review and meta-analysis. Am J Gastroenterol 2011; 106: 617-629.
  • 23. Ford AC, Khan KJ, Talley NJ, Moayyedi P. 5-Aminosalicylates prevent relapse of Crohn’s disease after surgically induced remission: systematic review and meta-analysis. Am J Gastroenterol 2011; 106: 413-420.
  • 24. Lichtenstein GR, Abreu MT, Cohen R, Tremaine W; American Gastroenterological Association. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology 2006; 130: 940-987.
  • 25. Lakatos PL, Golovics PA, David G, et al. Has there been a change in the natural history of Crohn’s disease? Surgical rates and medical management in a population-based inception cohort from Western Hungary between 1977–2009. Am J Gastroenterol 2012; 107: 579-588.
  • 26. Feagan BG, Rochon J, Fedorak RN, et al. Methotrexate for the treatment of Crohn’s disease. The North American Crohn’s Study Group Investigators. N Engl J Med 1995; 332: 292-297.
  • 27. Herfarth HH, Osterman MT, Isaacs KL, et al. Efficacy of methotrexate in ulcerative colitis: failure or promise. Inflamm Bowel Dis 2010; 16: 1421-1430.
  • 28. Stein RB, Hanauer SB. Comparative tolerability of treatments for inflammatory bowel disease. Drug Saf 2000; 23: 429-448.
  • 29. Ariyaratnam J, Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: a meta-analysis. Am J Gastroenterol 2014; 109: 163-169.
  • 30. Siegel CA. Review article: explaining risks of inflammatory bowel disease therapy to patients. Aliment Pharmacol Ther 2011; 33: 23-32.
  • 31. D’Haens G, Baert F, van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008; 371: 660-667.
  • 32. Colombel JF, Sandborn WJ, Reinisch W, et al. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 2010; 362: 1383-1395.
  • 33. Panaccione R, Ghosh S, Middleton S, et al. Combination therapy with infliximab and azathioprine is superior to monotherapy with either agent in ulcerative colitis. Gastroenterology 2014; 146: 392-400.e3.
  • 34. Croft A, Walsh A, Doecke J, et al. Outcomes of salvage therapy for steroid-refractory acute severe ulcerative colitis: ciclosporin vs. infliximab. Aliment Pharmacol Ther 2013; 38: 294-302.
  • 35. Ben-Horin S, Chowers Y. Review article: loss of response to anti-TNF treatments in Crohn’s disease. Aliment Pharmacol Ther 2011; 33: 987-995.
  • 36. Dave M, Purohit T, Razonable R, Loftus EV. Opportunistic infections due to inflammatory bowel disease therapy. Inflamm Bowel Dis 2014; 20: 196-212.
  • 37. Kotlyar DS, Osterman MT, Diamond RH, et al. A systematic review of factors that contribute to hepatosplenic T-cell lymphoma in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2011; 9: 36-41.e1.
  • 38. Raaschou P, Simard JF, Holmqvist M, Askling J; ARTIS Study Group. Rheumatoid arthritis, anti-tumour necrosis factor therapy, and risk of malignant melanoma: nationwide population based prospective cohort study from Sweden. BMJ 2013; 346: f1939.
  • 39. Fidder H, Schnitzler F, Ferrante M, et al. Long-term safety of infliximab for the treatment of inflammatory bowel disease: a single-centre cohort study. Gut 2009; 58: 501-508.
  • 40. Sandborn WJ, Feagan BG, Rutgeerts P, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2013; 369: 711-721.
  • 41. Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med 2013; 369: 699-710.
  • 42. Feagan BG, Sandborn WJ, Gasink C, et al. Ustekinumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2016; 375: 1946-1960.
  • 43. Ma C, Fedorak RN, Kaplan GG, et al. Long-term maintenance of clinical, endoscopic, and radiographic response to ustekinumab in moderate-to-severe Crohn’s disease: real-world experience from a multicenter cohort study. Inflamm Bowel Dis 2017; 23: 833-839.
  • 44. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368: 407-415.
  • 45. Paramsothy S, Kamm MA, Kaakoush NO, et al. Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial. Lancet 2017; 389: 1218-1228.
  • 46. Costello SP, Soo W, Bryant RV, et al. Systematic review with meta-analysis: faecal microbiota transplantation for the induction of remission for active ulcerative colitis. Aliment Pharmacol Ther 2017; 46: 213-224.
  • 47. Graff LA, Walker JR, Bernstein CN. Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management. Inflamm Bowel Dis 2009; 15: 1105-1118.
  • 48. Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2014; 8: 443-468.
  • 49. Sigall-Boneh R, Pfeffer-Gik T, Segal I, et al. Partial enteral nutrition with a Crohn’s disease exclusion diet is effective for induction of remission in children and young adults with Crohn’s disease. Inflamm Bowel Dis 2014; 20: 1353-1360.
  • 50. Lindberg E, Järnerot G, Huitfeldt B. Smoking in Crohn’s disease: effect on localisation and clinical course. Gut 1992; 33: 779-782.

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