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Interviewer: Inflammatory Bowel Disease treatment options. We'll talk about those next on The Scope.

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Interviewer: Dr. John Valentine is an expert in treating inflammatory diseases of the intestinal tract including inflammatory bowel disease. Dr. Valentine, after you've been diagnosed or you've diagnosed someone, I should say, with IBD, is there a standard treatment order that you follow or what can the person expect at that point?

Dr. Valentine: Well, there used to be a misconception that you'd start with the milder medications and work your way up, but people were failing. I think the better concept is to treat to the disease severity. If somebody has mild disease, see if you can get by with some of the milder medications. If somebody has obviously severe disease, you're wasting your time starting slow and the patient's going to get into other kinds of problems. It also makes a difference if you're talking about ulcerative colitis or Crohn's disease.

Let's start with ulcerative colitis. I would like to see everybody fail a class of drugs called mesalamine back in the '50s, '60s, and '70s, a drug was called sulfasalazine. That still exists, but they all deliver the same medication to the colon. Most patients will respond well to that. There is a proportion, 30-40% of those, that that class of drugs isn't enough. Then they need to get into medications to suppress their immune system.

We may use steroids such as prednisone in patients just to get them better quicker while you want to see if the mesalamine drugs will be effective for them. But if they're not effective, then steroids can give some prompt relief, but they're not good for your long run. They are full of complications.

Then we get into what we call steroid sparing therapies, which could include azathioprine, methotrexate, or anti-TNF medications, infliximab. Vedolizumab is a newer so-called biologic, but that blocks the signal that sends the inflammatory cells to the intestine.

Interviewer: Are there any drawbacks to those medications?

Dr. Valentine: Well, with the mesalamine medications, they are very safe. Every drug has potential side effects to it, including aspirin, but these drugs, like I've said, have been around since the '50s in one form or the other. So they have a long track record and they're very well tolerated for the most part. When you start getting into the medications that suppress the immune system or blocking a key component that we have for a reason, given what we're doing to the immune system, I think there are also surprisingly well-tolerated. But you do need to be aware of potential complications.

So we avoid chronic steroids because of effects on mood. You can get depressed, trouble sleeping, get irritable. It can push you over to be diabetic if you're prone to that already, weight gain, acne, other cosmetic changes can occur, as well as osteoporosis from long-term use. So we need to avoid long-term use of steroids.

The other medications, methotrexate, azathioprine is a therapy and we'll start with those. They can reduce your white counts so you need blood monitoring. Abnormal liver tests can occur with both of those so you need to monitor the liver enzyme. Look for irritation of the liver. There's also an increased risk of skin cancers and lymphoma with patients on azathioprine. Now, it's not dramatic, but there is an increased rate and patients need to be aware of that.

So then, you get into the anti-TNF medications. These are monoclonal antibody or biologic drugs that bind the protein in your immune system called tumor necrosis factor, which is very stimulating to the immune system. While there appears to be less of a risk of malignancy with those medications, it's not zero. You need to screen patients for exposure to tuberculosis because putting somebody who has been exposed but not been treated can let the TB run wild. Screening for TB and for Hepatitis B is very important for that class of drugs.

Interviewer: Sounds like some of these cures are just about as not fun as inflammatory bowel disease is.

Dr. Valentine: Well, if you don't need to be on those medications, you shouldn't be. But I think if you need them, the benefits outweigh the risks.

Interviewer: Got you.

Dr. Valentine: While these complications can occur, they're not very common.

Interviewer: That's good. When it comes to the treatments, it's all about just managing the symptoms or is it about actually suppressing the disease?

Dr. Valentine: It's suppressing the disease. You might be able to manage the symptoms with pain medications, antidiarrheal medications, but the inflammation is still there and problems will occur.

Interviewer: Yeah, all right. So let's talk about if you're diagnosed with Crohn's Disease, then. How do the treatments differ?

Dr. Valentine: So since Crohn's Disease likes to, or commonly affects, the small intestine, the mesalamine drugs don't work very well because they're designed to deliver to the colon. In addition, with Chon's Disease, rather than being just the lining of the bowel that's inflamed, the whole thickness of the bowel wall is inflamed so you need more potent medication. Mesalamine medications don't work very well for Crohn's Disease. Very mild, colonic Crohn's, I've seen it'd be effective. But if you have more severe disease, you need to move on.

The only thing to move on now is to immunosuppressant medications. The same ones I mentioned before. The azathioprine, methotrexate, the anti-TNF drugs, infliximab, adalimumab, certolizumab, and then the vedolizumab, the one that blocks the lymphocyte traffic, has also been approved. There have not been head-to-head comparisons, but it doesn't appear to work as well as the anti-TNF medications. So because you need to get into more aggressive medication, and because of the complications with Crohn's, you don't want to let that drag out too long.

Interviewer: What's somebody's eating or their lifestyle, or are there any changes they could make there that will help inflammatory bowel disease, or is that not even related?

Dr. Valentine: There are some things you could do to help the symptoms. So when you're bowel's inflamed, especially the colon, the job of the colon is to absorb water and to hold your stool until it's a convenient time to get rid of it. When it's inflamed, it's having a hard time doing that so certain foods that pull more water into your colon are going to give you more symptoms. So we advise people with the inflammation of their colon to avoid raw fruits and vegetables, high fiber foods until we get the inflammation under control.

Once it's under control, you can add that stuff back to your diet and tolerate just like before your diagnosis. In Crohn's disease involving the small intestine, but when the whole thickness of the bowel wall is inflamed, the lumen, the center part of the intestine, actually gets narrowed. So again, bulkier, fibrous foods may have a harder time getting through the narrowing, which give symptoms of abdominal pain, distention, and if bad enough, nausea and vomiting. So again, avoiding those until we get the inflammation under control is often recommended.

Interviewer: But it doesn't actually treat the problem, which as you indicated, if untreated, could cause bigger problems?

Dr. Valentine: Correct. I firmly believe we need better dietary studies in inflammatory bowel disease, but the studies that have been done to date haven't really identified any particular diet or lack of things in your diet that causes inflammatory bowel disease.

Interviewer: Are there any other common things that patients say to you that they wonder if it will help as opposed to taking some of the medications that you recommend? And what do we know about those?

Dr. Valentine: Diet comes up a lot and I think patients are frustrated and disappointed when I can't tell them how to change their diet. Probiotic supplements also come up frequently and in the test tube, they do have anti-inflammatory activity. But there are thousands of different species and strains of bacteria within the gut.

Most of the probiotic supplements have between one to 10 species of bacteria and we don't know which ones and how many and which ones you need for which disease processes. So they won't be harmful, but I really would have difficulty going to the medical journals and finding clinical trials of probiotic supplements showing they're of great benefit.

Interviewer: What can a patient expect for the rest of their life, then, since this is something that you manage and treat throughout the rest of your life as far as dealing with inflammatory bowel disease?

Dr. Valentine: Well, the need to stay on chronic medication and keep regular follow-ups with the gastroenterologist is important. Because we can't cure this, chronic treatment is needed. Then, if you have inflammation in your colon, after you've had the disease for about 10 years, you need to get into colon cancer screening surveillance programs because of the higher rate of colon cancer that's found in these patients.

So typically, it's a colonoscopy every two to three years after 10 years, and then current guidelines recommend a yearly colonoscopy after 20 years of inflammation in the colon. So if you have Crohn's disease only in the small intestine, the rate of colon cancer is not increased. That's another reason why to determine where in the bowel the inflammation is occurring.

Interviewer: As far as my lifestyle, if I'm on the medications that are managing the symptoms, it's taking care of the inflammation, which is the root cause, life relative is normal beyond that point?

Dr. Valentine: Except for having to remember to take your medication.

Interviewer: Yes.

Dr. Valentine: That is easy to do when you feel bad, but then when you're feeling well, you have to remember to take it.

Interviewer: Take that medication and you'll be fine.

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Interviewer: Diagnosing inflammatory bowel disease, or IBD, that's next on The Scope.

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Interviewer: Dr. John Valentine is an expert at treating inflammatory diseases of the intestinal tract, including inflammatory bowel disease, or IBD as some people know it. First of all, is there a difference between irritable and inflammatory bowel disease?

Dr. Valentine: Those two get confused quite often.

Interviewer: Okay.

Dr. Valentine: So irritable bowel syndrome is quite common. It is not inflammatory, can give you abdominal pain, cramps, diarrhea, or constipation. But inflammatory bowel disease is an immune-mediated process that causes inflammation in the GI tract that can result in similar symptoms, abdominal pain and diarrhea. But because of the inflammation, it can also lead to bleeding in the GI tract, fevers, and complications such as development of cancer if there's long-term inflammation, and the need for surgery.

Interviewer: So it's a little bit more of a nasty character?

Dr. Valentine: Yeah, I agree.

Interviewer: Yeah, okay. So I hear that inflammatory bowel disease is actually increasing quite a bit. Can you talk to how much?

Dr. Valentine: Well, it's increasing in both western countries, and then in countries that are now westernizing. China, India, South America are now starting to see an influx of inflammatory bowel disease and exactly why isn't clear. But because patients are diagnosed very young and we can't cure it, we can treat it, these patients are living with it. With the increased rate of new cases, some predictive modeling suggests that the number of people living with inflammatory bowel disease in North America will double in the next 10 years.

Interviewer: That doesn't sound very enjoyable for a lot of us, then.

Dr. Valentine: Well, fortunately, we have multiple treatment options. We can treat this, but we can't cure it.

Interviewer: All right. In another segment, we'll talk about treatment options for IBD. Because from what I understand, there's quite a few of them and it's probably worth its own particular podcast. So take me through the process that you'd use to diagnose someone's IBD.

Dr. Valentine: Well, typically a patient would come in with chronic symptoms. An infectious colitis, for example, of Salmonella, Shigella, the common bacterial infections, you may have similar symptoms, but they'll only last three to five days. If somebody comes in having blood in their stool, loose stools, maybe fevers and it's been going on for a couple weeks, then we start thinking about inflammatory bowel disease. Which we then need to differentiate between ulcerative colitis, which only involves the lining of the colon, and Crohn's disease, which can be anywhere in the GI tract, but tends to like the end of the small intestine, first part of the colon.

Interviewer: Are the symptoms for all those the same? Or do you use a little bit of a different diagnostic then to figure out specifically what somebody might be dealing with?

Dr. Valentine: Well, there is a tremendous overlap between the two. Where the inflammation is can make a big difference. If your inflammation is only at the very end of your small intestine, you may not have diarrhea at all. Where if the inflammation is in the rectum and lower part of the colon, then diarrhea and visible blood would be a more common feature. So we can get some hints as to which one we think it is, but we need to do some more diagnostic testing to straighten that out.

Interviewer: In addition to symptoms, are there other risk factors that you ask the patient about to help determine if that is indeed what they have?

Dr. Valentine: The risk factors don't exclude it, but it certainly increases the probability.

Interviewer: Okay.

Dr. Valentine: So the biggest risk factor we know for having inflammatory bowel disease is having a family member who has it. That being said, somebody needs to be first. But there's often a cluster of other immune-mediated diseases in the family, multiple sclerosis, rheumatoid arthritis, lupus or celiac disease. These are all different diseases that do share some genetic underpinning so that's why they tend to cluster together.

Interviewer: Do you find that patients do a pretty good job of self-diagnosing by the time they get to you?

Dr. Valentine: It depends. If they have a family member, especially a brother or sister with it, yeah, they know what the symptoms are and they come in, "I think I sort of have this." If they're the first in the family, they really don't know.

Interviewer: Okay. So what are some of the other diagnostics that you use to determine for sure if they have inflammatory bowel disease?

Dr. Valentine: Well, the number one cause of bloody diarrhea is infection so you always need to rule out infection. Sometimes, though, the infection can be the trigger. We treat that, but the inflammation won't go away.

Interviewer: Okay.

Dr. Valentine: So we have to rule out infection. The patient's age also can give you some hints.

Interviewer: Okay.

Dr. Valentine: So ulcerative colitis and Crohn's, they're a peak onset stage of 15 to 25. It can occur a whole lot younger. It can occur in the 60s. But a 25-year-old coming in with diarrhea for several weeks with blood in it, inflammatory bowel diseases goes to the top of my list.

Interviewer: Are there any tests or screenings that you use?

Dr. Valentine: A colonoscopy would be the primary diagnostic test. You want to be sure you know what you're treating, especially because some of the treatments involve immunosuppressant medications. So a colonoscopy, make sure you know whether it's ulcerative colitis or Crohn's. Make sure the pathology, what the pathologist sees under a microscope fits with that diagnosis and not some other bizarre or much less common etiologies.

If the colonoscopy doesn't reveal any problems, then imaging of the small intestine, and there are several ways of doing that. An MRI or a CT scan would be most common. Occasionally, the capsule endoscopy, but I'm really wary of people who get diagnosed based on images from a capsule endoscopy by itself.

Interviewer: Why is that?

Dr. Valentine: Lots of things can cause inflammation in the small intestine. Little discreet breaks could be caused by taking ibuprofen and similar types of medications. So when they even show these pictures to the experts, they have a hard time deciding what might be due to these ibuprofen-type medications and what might be due to Crohn's disease.

Interviewer: At this point in our conversation, if somebody is convinced at this point that they have inflammatory bowel disease, would they go to a general practitioner or their primary care physician first? Or come straight to you at this point?

Dr. Valentine: Well, like I said, need to exclude infection. So I think going to the primary care doctor to get the stool studies done to exclude Clostridium difficile infections, Salmonella, Shigella, campylobacter, the other bacteria that can cause inflammation in the colon would be the first step.

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updated: April 17, 2019
originally published: March 15, 2016