Seven Common Errors in the Management of IBD
02/06/2004

This update is taken from a lecture that I attended by perhaps the best IBD doctor and speaker alive – David Sachar, Professor Emeritus, Gastoenterology Division, Mount Sinai Medical Center, New York, NY. It is a summary of the common errors that physicians make in treating patients with inflammatory bowel disease.

1. The first error is under use of aminosalicylates or 5-ASA compounds. 5-ASA medications are extremely effective but only when taken in high enough doses. The best dose range for inducing remission is 4 to 4.8 grams a day – that is either 12 pills of Asacol or 16 pills of Pentasa a day. There are also topical agents that coat the colon directly; suppositories (Canasa) or enemas (Rowasa) that are extremely effective in treating inflammation in the rectum and the left side of the colon.
   
   
2. The second error is under use of 6-mercaptopurine or imuran. Although most physicians prescribe them, these doses are often too low. The target doses for most patients are 1-1.5 mg/kg for 6-MP and 2 to 2.5 mg/kg for imuran. There are now blood tests that can be sent to make sure the appropriate dose of medication has been given. Other positive signs that the medicine is working are decreased IBD symptoms of diarrhea and abdominal pain, and slight lowering of the white blood cell count.
   
   
3. The third error is misuse of steroids. While prednisone is very effective at inducing remission, it should not be continued for long periods of time (more then 2-3 months). The side effects such as bone loss, weight gain, and fatigue can be terrible and the medicine will lose its effectiveness over 6-12 months. The best medicine for maintaining remission in Crohn’s disease is 6-MP/imuran. 5-ASA medications also can be effective for maintaining remission in mild to moderate ulcerative colitis. Because of the bone loss patients experience during the first 6 WEEKS on steroids, calcium and vitamin D should always be started at the same time. Hydrocortisone enemas are helpful for left-sided colitis and budesonide is helpful for Crohn’s disease of the ileum and right colon. Both of these medicines have fewer side effects than traditional steroids.
   
   
4. The fourth error is delaying surgery in ulcerative colitis for too long a period of time. The goal of therapy in UC is not to save colons, but to save lives. For patients who have had UC for many years and have many side effects of steroids, surgery is probably a better option than further medical therapy. For a patient who has been newly diagnosed and does not have the complications of years of steroid use, cyclosporine can delay or prevent immediate surgery.
   
   
5. The fifth error is not using community resources. The gastroenterologist cannot treat the patient alone. Most patients would benefit from seeing a nutritionist and from support groups such as the Crohn’s and Colitis Foundation of American (www.CCFA.org).
   
   
6. The sixth error is treating every abdominal cramp and pain as if it were IBD. About 15% of the U.S. population has IBS or irritable bowel syndrome, which also causes cramps and diarrhea. Sometimes, patients need treatment for IBS rather than for IBD
   
   
7. The seventh and final error is misuse of infliximab. Infliximab is a very powerful drug, especially in patients who do not respond to steroids. However, infliximab should not be stopped after 1, 2, or 3 infusions. If it is working well, infliximab is indicated for maintenance therapy in patients with inflammatory or fistulizing Crohn’s disease. If infliximab is stopped and then restarted after a 4-month period of time, it may not be as effective. Use of 6-MP/imuran in addition to infliximab will help maintain remission and if possible, all patients should be given both at the same time.
   

(Last updated 02/06/04)