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Expert offers insight into pharmacotherapy in IBD, individualized treatment
PHILADELPHA — In the American Journal of Gastroenterology Lecture, Charles N. Bernstein, MD, outlined the current state and future direction of invasive bowel disease treatment in which he looked broadly at pharmacotherapy in bowel disease and discussed the need to look at each patient’s individual situation from remission to opiate use to stress levels.
Bernstein, of the University of Manitoba and director of the IBD Clinical and Research center in Winnipeg, Canada, suggested that thiopurines may have a role in Crohn’s disease, and that combination therapy with immunomodulators and anti-TNF inhibitors has shown positive results.
Charles N. Bernstein
“Many results show that every patient with IBD needs to be on therapy, and that, over time, they require increasingly stronger therapies,” Bernstein said. “But then we looked at prevalence at any one time of people using any kind of ulcerative colitis or IBD therapy and we found that by 7 to 8 years of disease, usage rates tended to hit plateaus.”
Bernstein said that some patients are not adherent, others are unable to afford drugs, and still others fail to make it to the doctor. “But, importantly, others are in deep remission and simply do not need to be on drugs,” he said. “Not every patient is as sick as the ones coming to our clinic. We need to try to understand the population in whom we can stop IBD therapy safely.”
Antibiotics are the primary approach to managing the microbiome, according to Bernstein. He noted that there are no data showing efficacy of probiotics in Crohn’s disease, but that some findings demonstrate that VSL#3 may have some activity against ulcerative colitis.
This brought the talk to the subject of fecal transplantation. “The issue with fecal transplant is that it is not a single agent,” he said. “It involves multiple agents from different donors.”
As for treating the symptoms of IBD, Bernstein warned caution with pain management. Many newly diagnosed patients with IBD are already using opiates, which puts them at risk for heavy use upon further prescriptions. “Depression and even death can result,” Bernstein said. “Please be wary of falling into slippery slope of repeated prescriptions for opiates.”
Finally, Bernstein talked about stress. He noted that patients with high rates of perceived stress believed that it was associated with a flare-up of IBD. “Was it just symptomatic disease or were they actually having active inflammation?” he said.
Disclosures: Bernstein reports associations with Abbvie, Forest, Pfizer, Shire and Takeda.