MEDICAL MANAGEMENT OF CROHN’S DISEASE 1. Diagnosis of IBD Crohn’s Disease (CD) • history & examination Characterised by patchy, transmural inflammation which may affect any • exclude infection EP A TR I A T I O part of the gastrointestinal tract N R • abdominal x-ray GENERAL HOSPITAL Symptoms include: • FBC, ELU, LFT, ESR, CRP DAW PARK • abdominal pain Southern Adelaide • sigmoidoscopy where disease is severe Health Service • diarrhoea • colonoscopy for mild to moderate disease • weight loss • histopathology. • +/-systemic symptoms of malaise, anorexia or fever. Management depends on 1) the Affected site: Ileal/ileocolonic/colonic/other and 2) the Disease pattern: inflammatory/stricturing/fistulising Active Disease Maintenance of Remission • Cease smoking 1. ILEOCOLONIC 2. FISTULISING • Fish Oil 2 capsules daily • Dietitian referral • MRI and EUA recommended • Corticosteroids, including Budesonide, are not effective MILD • Antibiotics first line therapy: • Mesalazine is of limited benefit, and is ineffective at doses <2mg daily • Mesalazine 4gm daily, although data limited Metronidazole 400mg tds or ciprofloxacin 500mg BD • Mainstay of therapy is immunomodulation with Azathioprine MILD - MODERATE • Azathioprine/6-Mercaptopurine once abscess excluded (2-2.5mg/kg/day or 6-Mercaptopurine (1-1.5mg/kg/day). • Prednisolone 40-60mg daily (up to 1mg/kg), reducing to zero over • Infliximab reserved for refractory fistulae (3 infusions of 5mg/kg given • Need regular CBE and LFTs if on immunomodulators as follows: 8-12 weeks once clinical response achieved. at weeks 0, 2 & 6) - weekly for 4 weeks, then monthly for the next 2 months then OR • Surgery (including seton drainage) appropriate for persistent or 3 monthly complex fistulae Budesonide 9 mg daily reducing to zero over 6 weeks if Prednisolone • If Azathioprine/6-MP therapy fails or intolerance consider Methotrexate not tolerated • Dietitian referral. as follows: • Addition of Metronidazole 20mg/kg in bd divided dose may give benefit - Commence at 25mg IM weekly for 12 weeks, then consider weekly SEVERE oral dosing. When on methotrexate, also should have folic acid • IV Hydrocortisone 100mg QID 5-10mg a week • Consider addition of IV Metronidazole 500mg bd • If Immunomodulator therapy fails consider Infliximab (5mg/kg) infusions • If poor response after 5-7 days consider Infliximab infusion 5mg/kg as at 8 weekly intervals or upon evidence of flare a bridge to Azathioprine/6-Mercaptopurine therapy • Dietitian referral • Avoid Infliximab in stricturing disease & be aware of its reduced efficacy • Consider DEXA, as osteoporosis common in Crohn’s Disease. in smokers. Preventon of Post-Operative Recurrence General Management of IBD Principals • Cessation of smoking reduces relapses • Refer all patients to: • Mesalazine at doses >2gm daily is effective in small bowel disease, - IBD Nurse Coordinator at FMC, contact 8204 3942 but not following colonic resection OR • Mainstay of therapy in the prevention of post-op relapse is - IBD Specialist Nurse at RGH, contact 8275 1745 Azathioprine/6-Mercaptopurine • Discuss and make treatment decisions with the patient • Metronidazole (20mg/kg/day for 3 months) is effective in recurrence after ileo-colonic resection for up to 18 months. Not well tolerated- • Ensure rapid access to clinic appointments peripheral neuropathy a major side effect. • Provide clear management plans • As non-specific pain is a common feature of IBD, where possible deter BSG Guidelines for the Management of Crohn’s Disease. Reference:GUT 2004 • Created by the Southern Adelaide IBD Service June 2006, enquiries 8204 3942 mine cause & treat. Avoid analgesics; tramadol if necessary.