Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

¹James Gregor, MD,²Co-authors: John Howard, MD, Nitin Khanna, MD, and Nilesh Chande, MD,

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Abstract: Informed patients are one of the most important assets available in the management of patients with ulcerative colitis. Clinical experience reinforces that most patients have similar questions upon diagnosis. Anticipating these questions and tailoring them to a particular patient's disease severity and extent should not only streamline follow-up but also mitigate confusion and augment the benefit of the plethora of information available in the 21st century. Using our local experience, we have defined the 10 most common questions asked by patients and modified the answers, where necessary, to improve their specificity to patients with ulcerative proctitis, left-sided ulcerative colitis, and pancolitis.

Key Words: ulcerative colitis, patient, questions, classification, management.

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Patients can be relatively ill informed regarding the nature of their UC, its management, and its ultimate prognosis.

Generally, disease extent is divided into three categories: ulcerative proctitis, left-sided disease, and pancolitis.

A simple approach with frequently asked questions (FAQs) is a highly desirable and efficient means of transmitting information.

Clinical experience reinforces that most patients have similar questions upon diagnosis with UC.

Anticipating these questions and tailoring them to a particular patient's disease severity and extent should streamline follow-up and also mitigate confusion.

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Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

Geoffrey C. Nguyen, MD, PhD,

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Abstract: 5-Aminosalicylates (5-ASAs) are considered first-line therapy for mild to moderate ulcerative colitis because of their proven effectiveness and safety profile, even in pregnancy. One formulation, however, contains dibutyl phthalate (DBP) in its coating. Though DBP may cause disruptions in utero reproductive development and other congenital abnormalities in rodents, it is unclear whether it leads to physiologically significant fetal abnormalities in humans. The US Food and Drug Administration has changed its classification for DBP-containing 5-ASAs from pregnancy category B to pregnancy category C to reflect a greater degree of uncertainty regarding its effect in humans. For pregnant women with ulcerative colitis, the most important message is to take their inflammatory bowel disease (IBD) medications to prevent disease relapse, which may have the most adverse effects on pregnancy. Physicians should, however, discuss with young women who are taking 5-ASA with DBP the benefits and risks of switching to another formulation of 5-ASA without the DBP compound.

Key Words: phthalates, 5-aminosalicylate, ulcerative colitis, dibutyl phthalate, pregnancy.

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5-Aminosalicylates (5-ASAs) are effective for the treatment of mild to moderate ulcerative colitis and are generally regarded as safe to use, even during pregnancy.

Dibutyl phthalate (DBP) is found in the coating of certain formulations of 5-ASA, and in rodents has been shown to be associated with developmental and congenital abnormalities.

Though phthalates have been shown to be associated with some indicators of reduced masculinization among male fetuses, there is insufficient evidence to prove that it leads to significant harmful effects.

There are several formulations of 5-ASA that do not contain DBP.

Asacol, which contains DBP, is categorized as a pregnancy category C drug, while most other 5-ASAs are in pregnancy category B.

It should be emphasized to pregnant women that taking medications for their inflammatory bowel disease is important because the disease has a strong impact on, not just their health, but the health of their fetus too.

Women of child-bearing age who are taking a DBP-containing 5-ASA should have a discussion regarding the benefits and risks of switching to another 5-ASA, preferably before pregnancy.

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Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

Brian Bressler, MD, MS, FRCPC,

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Abstract: A 28-year-old male presented to our office for a consultation about his bloody bowel movements. Colonoscopy revealed moderately active left-sided ulcerative colitis extending from the anal verge up to the mid-descending colon. He was prescribed both oral and rectal 5-ASAs for induction therapy, and is in remission. Appropriate patient education has helped him realize that the best chance of staying in remission is to continue on his medical therapy.

Key Words: ulcerative colitis, 5-aminosalicylate, medication adherence, dysplasia surveillance, rectal inflammation.

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Stool samples should be tested for infectious causes of bloody diarrhea.

Treatment with steroids should be avoided, if possible, as this medication carries the most risk.

In most cases, clinical remission is an acceptable outcome.

In patients newly diagnosed with left-sided ulcerative colitis, if macroscopic evidence of inflammation stops before 35 cm from the anal verge, it is critical to take biopsies in the proximal left colon in normal-appearing mucosa to determine whether a patient with left-sided disease will require dysplasia surveillance.

Patient education at each follow-up visit helps to ensure medication adherence.

We need to help patients understand that UC can be managed with medication, but not cured.

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A. Hillary Steinhart, M.D., est membre du service de gastroentérologie du Mount Sinai Hospital/University Health Network, et est professeur de médecine à l'Université de Toronto à Toronto (Ontario).

Résumé
Bien qu'une thérapie d'entretien pour la colite ulcéreuse permette généralement d'obtenir une rémission clinique, de nombreuses études ont montré que les patients en rémission clinique pourraient présenter des degrés variables d'inflammation de la muqueuse. Il semble que les patients présentant le plus haut degré d'inflammation évolutive de la muqueuse, malgré l'absence de symptômes cliniques, sont plus susceptibles de subir une poussée symptomatique à court terme. Chez les patients atteints de CU, le taux de calprotectine dans les selles est associé non seulement à la présence ou l'absence d'inflammation de la muqueuse, mais également au degré de gravité clinique de la CU. Ces observations soulèvent la possibilité d'utiliser le taux de calprotectine fécale pour surveiller de manière non effractive les patients en rémission clinique, et modifier le traitement de ceux montrant une augmentation du taux de calprotectine fécale, et ce, avant la réapparition des symptômes.
Mots clés : colite ulcéreuse, calprotectine fécale, prédiction des poussées, inflammation de la muqueuse, surveillance non effractive.

Brian Bressler, M.D., M.Sc., FRCPC, est professeur adjoint clini-que de médecine dans
le service de gastroentérologie du St Paul's Hospital, Université de la Colombie-Britannique, à Vancouver (Colombie-Britannique).

Résumé
Un homme de 28 ans est venu nous consulter pour ses selles sanglantes. La coloscopie a mis en évidence une colite ulcéreuse gauche modérément évolutive, affectant une région allant de la marge de l'anus jusqu'au milieu du côlon descendant. Suite à un traitement d'induction avec des 5-AAS par voie orale et rectale, le patient est maintenant en rémission. Une éducation adaptée au patient lui a permis de réaliser que le meilleur moyen pour lui de rester en rémission était de continuer le traitement médicamenteux.
Mots clés : colite ulcéreuse, 5-aminosalicylate, respect du traitement médicamenteux, surveillance de la dysplasie, inflammation du rectum.

Geoffrey C. Nguyen, M.D., Ph. D., est professeur de médecine adjoint au Centre for Inflammatory Bowel Disease du Mount Sinai Hospital, Université de Toronto, Toronto (Ontario).

Résumé
Les 5-aminosalicylates (5-AAS) représentent le traitement de première intention pour les patients atteints de colite ulcéreuse (CU) légère à modérée, en raison de leur efficacité prouvée et de leur profil d'innocuité, même pour les femmes enceintes. Cependant, une préparation de 5-AAS possède un revêtement contenant du phtalate de dibutyle (DBP). Bien que, chez les rongeurs, le DBP puisse entraîner des troubles du développement reproducteur et d'autres anomalies congénitales in utero, on ne sait pas si le DBP provoque des anomalies foetales importantes sur le plan physiologique chez les humains. La Federal Drug Administration a modifié la classification des 5-AAS contenant du DBP en les faisant passer de la classe B à la classe C durant la grossesse, afin de refléter le degré plus grand d'incertitude concernant l'effet du DBP chez les humains. Le message le plus important destiné aux femmes enceintes atteintes de CU consiste à prendre les médicaments contre la CU afin d'empêcher une rechute de la maladie, qui pourrait entraîner le plus d'effets indésirables sur la grossesse. Cependant, les médecins doivent discuter avec les jeunes femmes prenant des 5-AAS contenant du DBP des bienfaits et des risques de prendre une autre préparation de 5-AAS sans DBP.
Mots clés : phtalates, 5-aminosalicylate, colite ulcéreuse, phtalate de dibutyle, grossesse.

James Gregor, M.D., est membre du département de gastroentérologie de l'Université Western Ontario, London (Ontario).
Co-auteurs : John Howard, M.D., Nitin Khanna, M.D. et Nilesh Chande, M.D. sont membres du département de gastro-entérologie du London Health Sciences Centre (Université Western) London (Ontario).

Résumé
L'un des atouts les plus importants dans la prise en charge des patients atteints de colite ulcéreuse consiste à avoir des patients bien informés. L'expérience clinique montre que la plupart des patients ont des questions similaires lors de leur diagnostic. En anticipant ces questions et en les adaptant à la gravité et l'étendue de la maladie d'un patient, il est possible non seulement de simplifier le suivi, mais également de réduire la confusion et d'augmenter les bienfaits apportés par la pléthore de renseignements disponibles au 21^e siècle. D'après notre expérience locale, nous avons défini les 10 questions les plus couramment posées par les patients et modifié les réponses, au besoin, pour qu'elles soient mieux adaptées aux patients atteints de rectite ou proctite ulcéreuse, de colite ulcéreuse gauche ou de pancolite.
Mos clés : colite ulcéreuse, patient, questions, classification, prise en charge.

Alexander I. Aspinall, MD, PhD and Jon B. Meddings, MD, FRCPC, Division of Gastroenterology, Faculty of Medicine, University of Calgary, Calgary, AB.

The inflammatory bowel diseases (IBD)--Crohn's disease (CD) and ulcerative colitis (UC)--have a second peak of onset after the age of 60. Discerning IBD from alternate diagnoses is a great challenge in the geriatric population, as other diseases commonly encountered in the elderly can mimic IBD. The possibilities include ischemic colitis, diverticulitis and infectious colitis. Diagnosing and treating IBD should involve consultation with a gastroenterologist, but the approaches do not vary significantly from the strategies used in younger patients. Therapeutic modalities used in younger age groups are also applicable to the geriatric population, but great attention needs to be given to side effects and drug interactions.
Key words: inflammatory bowel, crohn's disease, ulcerative colitis, differential diagnosis

Epidemiology and Pathophysiology
The inflammatory bowel diseases--Crohn's disease (CD) and ulcerative colitis (UC)--are illnesses of unknown cause.