Digestive Disease Week Highlight: How IBD Therapy is Changing
Each year, gastroenterologists around the world convene at one of two major gastrointestinal (GI) conferences to review concepts and discuss updates in anything and everything GI. A few weeks ago, I had the pleasure of attending one of those meetings, Digestive Disease Week (DDW), and brought back with me many learning pearls which will impact my practice. This post will outline some of the highlights from the conference pertaining to IBD. You can see more highlights of DDW on my Twitter feed, where I live tweeted the event.
The goals of treating IBD include inducing symptom remission, maintaining remission without the use of steroids, enhancing quality of life, preventing and/or treating complications of the disease, and avoiding serious short- and long-term side effects of treatment medications. In the past, treatment of Crohn’s Disease (CD) typically started with the weakest, least potent medications, such as corticosteroids, with “step-up care” to immunomodulators then biologics until the disease was controlled. The strategy for treating CD has evolved over time from the typical step-up approach to an accelerated step-up approach to now an early step-down approach for those with moderate to severe CD. Patients are now stratified to a certain path of treatment based on various disease factors, such as age of onset, early surgery, small intestines involvement, and extent of disease.
Major advances in treatment of IBD in the last decade include great availability of novel therapies that are very safe and effective, gaining more tools to communicate risks of disease and intervention with therapies, and shifting the goal of therapy from symptom-based to more objective parameters, such as laboratory tests. While clinical symptoms will always be a critical component in managing disease, objective factors can help manage treatment regimens when it comes to deciding whether to step-up therapy, change medication doses, or even de-escalate therapy (decrease doses or stop certain medications). Increasingly, monitoring levels of the inflammatory markers CRP and fecal calprotectin can help guide such decisions. These markers have been shown to help predict Crohn’s recurrence, as well, which would allow for pre-emptive medication dose adjustments before loss of response to a medication or a relapse in disease. De-escalation of therapy is a relatively newer concept in managing IBD. While this is possible, it needs to be considered only on an individual basis, and the patient needs to be closely monitored after de-escalation of therapy. Also, at this time, it is recommended that patients continue some type of medication and not come off all of their therapies. In other words, stopping all therapy is not recommended.
Nutritional deficiencies in IBD occur either from the disease itself, or due to side effects from medications. Iron and vitamin B12 deficiencies occur secondary to the disease itself. Inflammation results in increased inhibition of iron absorption. The need for and mode of supplementation (intravenous or tablets) depends on the degree of deficiency and response to oral tablets. Those with IBD affecting the terminal ileum, or end portion of the small intestines where it attaches to the colon, are at risk for vitamin B12 deficiency, and this should be supplemented if needed. Corticosteroids can cause vitamin D deficiency. Therefore, patients taking steroids should have vitamin D levels and bone density monitored due to the risk for osteopenia or osteoporosis. It is important to note that there is no special diet for IBD. However, it is important to work with nutritionists and dieticians to ensure that you are maximizing nutrient intake, and monitor nutrients when taking supplementation.
Managing IBD is extremely complicated and involves very individual-specific regimens and monitoring. Maintaining open communication with your health care providers is key in order to optimize medication regimens, nutrition status, and quality of life.