Crohn's Disease (cont.)
5-ASA rectal medications (Rowasa Canasa)
Rowasa is 5-ASA in enema form. 5-ASA by enema is most useful for treating
ulcerative colitis involving only the distal colon since the enema easily can
reach the inflamed tissues of the distal colon. Rowasa also is used in treating
Crohn's disease in which there is inflammation in and near the rectum. Each
Rowasa enema contains 4 grams of 5-ASA. The enema usually is administered at
bedtime, and patients are encouraged to retain the enema through the night. The
enema contains sulfite and should not be used by patients with sulfite allergy.
Otherwise, Rowasa enemas are safe and well-tolerated.
Canasa is 5-ASA in suppository form. It is used for treating ulcerative
proctitis. Each suppository contains 500 mg of 5-ASA and usually is administered
twice daily.
Both enemas and suppositories have been shown to be effective in maintaining
remission in patients with ulcerative colitis limited to the distal colon and
rectum.
Corticosteroids
Corticosteroids (for example, prednisone, prednisolone, hydrocortisone, etc.) have
been used for many years to treat patients with moderate to severe Crohn's
disease and ulcerative colitis and to treat patients who fail to respond to
5-ASA. Unlike 5-ASA, corticosteroids do not require direct contact with the
inflamed intestinal tissues to be effective.
Oral corticosteroids are potent antiinflammatory medications. After
absorption, corticosteroids exert prompt antiinflammatory actions throughout
the body, including the intestines. Consequently, they are used in treating
Crohn's disease anywhere in the small intestine, as well as ulcerative and
Crohn's colitis. In critically ill patients, intravenous corticosteroids (such
as hydrocortisone) can be given in the hospital. For patients with proctitis,
hydrocortisone enemas (Cortenema) can be used to deliver the corticosteroid
directly to the inflamed tissue. By using the corticosteroid topically, less of
it is absorbed into the body and the frequency and severity of side effects are
lessened (but not eliminated) as compared with systemic corticosteroids.
Corticosteroids are faster-acting than 5-ASA, and patients frequently
experience improvement in their symptoms within days of beginning them.
Corticosteroids, however, do not appear to be useful in maintaining remission in
Crohn's disease and ulcerative colitis or in preventing the return of Crohn's
disease after surgery.
Side effects of corticosteroids
The frequency and severity of side effects of corticosteroids depend on the
dose and duration of their use. Short courses of corticosteroids, for example,
usually are well-tolerated with few and mild side effects. Long-term use of high
doses of corticosteroids usually produces predictable and potentially serious
side effects. Common side effects include:
- rounding of the face (moon face),
- acne,
- increased body hair,
- diabetes,
- weight gain,
- high blood pressure,
- cataracts,
- glaucoma,
- increased susceptibility to infections,
- muscle weakness,
- depression,
- insomnia,
- mood swings,
- personality changes,
- irritability, and
- thinning of the bones (osteoporosis) with fractures of the spine.
Children
receiving corticosteroids experience stunted growth.
The most serious complication from long term corticosteroid use is aseptic
necrosis of the hip joints. Aseptic necrosis is a condition in which there is
death and degeneration of the hip bone. It is a painful condition that can
ultimately lead to the need for surgical replacement of the hip. Aseptic
necrosis also has been reported in the knee joints. It is not known how
corticosteroids cause aseptic necrosis. The estimated incidence of aseptic
necrosis among corticosteroid users is 3%-4%. Patients on corticosteroids who
develop pain in the hips or knees should report the pain to their doctors
promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids
might decrease the severity of the aseptic necrosis and the need for hip
replacement surgery.
Prolonged use of corticosteroids can depress the ability of the body's
adrenal glands to produce cortisol (a natural corticosteroid necessary for
proper functioning of the body). Therefore, abruptly discontinuing
corticosteroids can cause symptoms due to a lack of natural cortisol (a
condition called adrenal insufficiency). Symptoms of adrenal insufficiency
include nausea, vomiting, and even shock. Withdrawing corticosteroids too
quickly also can produce symptoms of
joint pain, fever, and malaise. Therefore,
when corticosteroids are discontinued, the dose usually is tapered gradually
rather than stopped abruptly.
Even after corticosteroids are discontinued, the adrenal glands' ability to
produce cortisol can remain depressed from months up to two years. The depressed
adrenal glands may not be able to produce increased amounts of cortisol to help
the body handle the stress of accidents, surgery, and infections. Therefore, patients
need additional corticosteroids during stressful situations to avoid developing
adrenal insufficiency. Because corticosteroids are not useful in maintaining
remission in ulcerative colitis and Crohn's disease, and because they have
predictable and potentially serious side effects, they should be used for the
shortest possible length of time.
Proper use of corticosteroids
Once the decision is made to use systemic corticosteroids, treatment usually
is initiated with prednisone, 40-60 mg daily. The majority of patients with
Crohn's disease respond with an improvement in symptoms within a few weeks. Once
symptoms have improved, prednisone is reduced by 5-10 mg per week until a dose
of 20 mg per day is reached. The dose then is reduced at a slower rate until the
corticosteroid is discontinued. Gradually reducing corticosteroids not only
minimizes the symptoms of adrenal insufficiency, it also reduces the chances of
an abrupt recurrence of inflammation.
Many doctors use 5-ASA compounds and corticosteroids together. In patients
who achieve remission with corticosteroids, 5-ASA compounds often are continued alone to
maintain remission.
In patients whose symptoms return corticosteroids are slowly being reduced, the dose of corticosteroids is increased slightly to control the symptoms.
Once the symptoms are under control, the reduction of corticosteroids can resume at a slower pace.
Unfortunately, many patients who require corticosteroids to induce remissions
become corticosteroid dependent. These patients consistently develop symptoms
whenever the corticosteroid dose falls below a certain level. In such patients
who are corticosteroid dependent as well as in patients who are unresponsive to
corticosteroids and other antiinflammatory medications, immuno-modulator
medications or surgery must be considered. The management of patients who are
corticosteroid dependent or patients with severe disease that responds poorly to
medications is complex. Doctors who are experienced in treating ulcerative
colitis and Crohn's disease and in using immuno-modulators should evaluate
these patients.
Prevention of osteoporosis
Long-term use of corticosteroids can cause osteoporosis. Calcium is very
important in the formation and maintenance of healthy bones. Corticosteroids
decrease the absorption of calcium from the intestine and increase the loss of
calcium from the kidneys. Increasing dietary calcium intake is important but
alone cannot halt corticosteroid-induced osteoporosis. To prevent or minimize
osteoporosis, management of patients on long-term corticosteroids should
include:
- Adequate intake of calcium (1000 mg daily in
premenopausal women, 1,500 mg daily in postmenopausal women) and vitamin D (800
units daily).
- Periodic review with the doctor of the need for
continued corticosteroid treatment and use of the lowest effective dose if
continued treatment is necessary.
- For patients taking corticosteroids for more than three
months, a bone density study may be helpful in determining the extent of bone
loss and the need for more aggressive treatment.
- Regular weight-bearing exercise and
stopping smoking (cigarettes).
- Discussion with the doctor regarding the use of alendronate (Fosamax),
risedronate (Actonel), or
etidronate (Didronel) to prevent or treat
corticosteroid-induced osteoporosis.
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