Managing Patients With Mild Crohn Disease

In this podcast, Charles Bernstein, MD, discusses the definition of mild Crohn disease, treatment and therapeutic options for managing patients with mild Crohn disease, and a holistic approach to managing patients with mild Crohn disease. Dr Bernstein also spoke about these topics during a session at The Advances in Inflammatory Bowel Diseases (AIBD) conference 2022 titled “Managing Mild Crohn’s.”

Additional Resource

• Charabaty A, Bernstein C, Clarke K, Dubinsky MC, Issokson K. Managing mild Crohn's. Talk presented at: AIBD 2022; December 5-7, 2022; Orlando FL. Accessed November 3, 2022. https://www.advancesinibd.com/

Charles Bernstein, MD, is a gastroenterologist and the Director of the IBD Clinical Research Center at the University of Manitoba (Winnipeg, Canada).

TRANSCRIPTION:

Jessica Ganga: Hello, everyone, and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I'm Jessica Ganga, along with your moderator, Jessica Bard, with Consultant360, a multidisciplinary medical information network.

Dr. Charles Bernstein is here to speak with us today about the panel he is a part of at AIBD 2022 titled Managing Mild Crohn's. Dr. Bernstein is a gastroenterologist and the director of the IBD Clinical Research Center at the University of Manitoba in Winnipeg, Canada. Let's listen in.

Jessica Bard: We were talking about your panel discussion at AIBD today, Managing Mild Crohn's Disease. What do you perceive to be mild Crohn's disease?

Charles Bernstein, MD: Well, that's a great question, Jessica, and really not easily answered so I'm glad that was your first one so that we could stumble through the first discussion. It's a common paradigm to try to divide Crohn's disease or ulcerative colitis into mild, moderate, and severe. It's a flawed paradigm because the question is are we asking about somebody's disease over the spectrum of years of their disease? Has their disease been mild? Have they never really needed surgery? Have they never had fistulizing disease? Have they been on minimal therapy? That's certainly somebody who's got mild disease. Or are we asking about our patient today who has disease that's in remission or minimal symptoms and they're feeling great, but the reality is they've been on anti-TNF for 10 years and eight to 10 years ago they had train wreck symptoms where they needed surgery and they had fistulas but we've gotten them better and we've kept them better. So which one of those are mild? Because they're very different patients.

So just focusing or asking the question how do you manage mild Crohn's disease, it's a cop out, but it really depends. It depends on what our definition of mild is. I think we all know when somebody's minimally symptomatic and doing well and I think if we think of that, we've got patients who got there with minimal therapy and we've got patients who've gotten there with surgery and/or biologic therapy or struggled a lot for three or four years and we finally got them to a place where they're mild.

Maybe the most focused way to talk about this is people who have mild disease in their first year of diagnosis, how are we going to approach them? Because it's very different than approaching somebody who's clearly got very active, difficult disease in that first year of diagnosis. That's a whole other discussion. So maybe we can discuss a person who we consider to have mild disease in that first year of diagnosis.

Jessica Bard: Great. And then going into that, what treatment options do you consider in mild Crohn's disease?

Dr Bernstein: So it really, again, depends and that's just the way management of IBD is, it always depends. And it depends on where the disease is and it depends on what type of disease it is. So for example, is the mild Crohn's disease just a short segment of mild inflammatory ileal disease that either we've discovered because the patient had mild symptoms or we discovered because we were scoping the patient, we got into their ileum and we can see that they have, actually, ileal Crohn's disease. Or maybe we were scoping them because they had iron deficiency anemia. Is the disease in their colon and are we calling them Crohn's disease but we could potentially treat them like they have ulcerative colitis?

Or do they have disease in their rectum where they have a bit of deep ulceration but they actually feel fairly well? So we're worried that their rectal disease isn't going to heal so easily but they're not having much in the way of symptoms.

So it really depends on what kind of a patient we're dealing with and what are our therapeutic options. If somebody has minimal symptoms, one option is symptomatic therapy where we can use antidiarrheals on the days that they may have diarrhea. If they've got loose or mushy stools we may use stool bulking agents like psyllium. If they have some nausea that we can get away with either over-the-counter anti-nauseas or even the occasional ondansetron. So one way is just symptomatic treatment when people are mostly well. We're always afraid that if we don't treat the underlying disease they're going to progress and we don't have good markers to know who is a patient who's going to progress. But I can tell you that, in the scenario that I presented, the person with very mild ileal inflammation, that person is much less likely to progress.

Dr Bernstein:Then the person with rectal ulceration that's a little bit deep who's feeling good but we know that the rectal disease is there because that can become a very difficult disease to manage. So I'm going to give that person with mild ileal disease a different approach than that person with deeper rectal disease. Now the person with, and I'm going to come back to that, the person with focal mild colitis, those persons, we typically don't like to use 5-ASA therapy in Crohn's disease. 5-ASA therapy is a local therapy. It usually works superficially in the colon and it's an excellent therapy in UC and there's not great data about its effectiveness in Crohn's disease. But there are patients who have mild focal colitis that we're going to label as Crohn's disease for whatever reason that I would give them a 5-ASA if that's all they had. It's very easy therapy to take. It's mild and it's well tolerated.

If a person has that mild ileal disease but they have some symptoms I may give them a trial of budesonide, an oral budesonide, that's formulated to be released in the ileum and right colon and rapidly metabolized. The problem with that approach, of course, if it works, it's helpful to us to have us understand that using an immune anti-inflammatory like a budesonide, a steroid, is helpful but we don't really have a long-term plan if we're using budesonide because budesonide is not a long-term solution. Steroids are not used as maintenance agents in Crohn's disease but it can be helpful in the short term.

Now I've been one of the guys over the many years that has been bucking the IBD mafia in the biologic era of still using monotherapy with thiopurines. And I think that they still may have a role, monotherapy with thiopurines, especially in this category of mild ileal disease. I'm more enthusiastic about using them in females because the rare risk of lymphoma, especially hepatosplenic T-cell lymphoma, seems to be more male dominated than female dominated. And I'm more enthusiastic about using it in younger people. But they do require some work in terms of surveillance of blood counts et cetera, or liver enzymes, but they are oral and certainly young people like to take oral medications as opposed to being hooked up to an IV or they want to go away to university, they want to travel, they want to know that it's going to be easy.

Dr Bernstein: If a patient has more active disease endoscopically or radiologically but very mild symptoms, that person I may be more aggressive with and be having frank discussions about, "You know, you feel good and you're not disrupting your life but you need a biologic therapy because I'm worried this is not going to go well and I want to nip this in the bud."

So there's not a one-size-fits-all approach to quote, unquote "mild Crohn's disease." I get back to my initial response, it depends.

Jessica Bard: Other than medical treatment, holistically how do you manage a patient with mild Crohn's disease?

Dr Bernstein: Well, I think anybody with Crohn's disease or ulcerative colitis needs to be holistically managed. In other words, they need the expertise of the gastroenterologist to decide on when it's appropriate to do investigations related to their disease and what type of therapies, just like the conversation we just had. However, there's much more to managing inflammatory bowel disease, including Crohn's disease, than just what the gastroenterologist has to offer.

There's a very high incidence of mood disorders and generalized anxiety disorders in persons with IBD and I think, A, in the GI clinic, in the IBD clinic, we need to recognize that and we need to have our friendly psychologist or therapist who we can refer to when we recognize it. And if we don't recognize it, it may be appropriate to have routine screening because maybe we're not either skilled enough to recognize it or the patient doesn't necessarily want to come forward and discuss some of the things that are really bothering them in their life. So I do think that some mental health professionals need to be on our team with IBD patients. Either you have them within your clinic model and it's a routine, or you have them available when you're really identifying certain issues.

Dr Bernstein: I think managing a person with IBD today includes managing their nutrition in a different way than it did 50 years ago when patients with Crohn's disease presented malnourished and we needed to maximize their nutrition. We see obese patients with Crohn's disease, especially if they have mild Crohn's disease. They may be even more likely to be obese as part of... North Americans, we tend to be obese and we need work on a healthy diet. But there's all kinds of information emerging these days about more inflammatory versus less inflammatory type of diets and a dietician can help with that.

And persons with IBD need help with social services. Not everybody with IBD, when you write them a prescription, can just bounce into their neighborhood pharmacy and get whatever drug it is that you've prescribed either because they can afford it or have great insurance so that's an issue. And then there's all kinds of issues about family dynamics and either childcare or elder care. And so for any chronic disease, and Crohn's disease is certainly one, we really need a multi-professional approach. It's no longer just the gastroenterologist and the primary care physician.

Jessica Bard: Now we know there's a lot to cover and we're looking forward to the panel and hearing you speak with some of the other panelists about some of the controversies in managing mild Crohn's disease but is there anything else that you'd like to add today for the podcast? Anything else that we missed?

Dr Bernstein: No, I think sometimes we diagnose mild Crohn's disease when we're managing patients with other conditions. And so our rheumatology colleague is managing somebody with ankylosing spondylitis and notices that they're iron deficient and they send us a consult because they're not on NSAIDs, there's no reason why they should be iron deficient. And we work them up and we find that somewhat silent, brewing Crohn's disease as an example. So they may come to us in that way.

For our pediatric friends, they're more likely to see new diagnoses of Crohn's disease when they present with, for instance, a monoarticular arthritis or some weird inflammatory skin rash and ultimately the child isn't necessarily complaining of diarrhea or belly pain but that's where we get to. Or the young woman who's got delayed menstrual periods or delayed growth.

So there's a spectrum across the ages of how this may present but particularly for kids where a lot of things are evolving, growth, sexual maturation, those things may be stunted and that may be the way Crohn's disease presents. So I think an excellent general internist, general pediatrician, primary care physician needs to remember about Crohn's disease and ulcerative colitis when they're thinking about the differential diagnosis of systemic symptoms and systemic disease.

Jessica Bard: Dr Bernstein, thank you so much for joining us on the podcast today. We'll look forward to your sessions at AIBD 2022.

Dr Bernstein: Thank you.