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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.
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With reference to the recent excellent review article on ulcerative colitis1 we were surprised by the omission of topical steroids as a treatment for flares of distal ulcerative colitis. Steroid enemas have been used since the 1950s2 with a wealth of evidence suggesting they are effective as a treatment for mild to moderate flares of ulcerative colitis. Recent data have shown that mesalazine enemas are more effective than steroid enemas in inducing remission3 and steroid enemas should still be considered an important treatment option. Both European and UK (ECCO4 and BSG5 ) guidelines advise prednisolone enemas as an alternative in patients with distal disease who do not tolerate topical mesalazine. ECCO go on to suggest using both topical prednisolone and mesalazine enemas in combination.
Steroid enemas can also be useful in some patients prior to using mesalazine enemas as by reducing inflammation they can increase subsequent retention of mesalazine enemas. Used properly in patients with distal disease they can also deliver effective topical treatment to the affected colon without the inherent risks of systemic steroids.
References
1. Ford AC et al. Ulcerative colitis; BMJ 2013;346:f432
2. Matts SGF. Betamethasone enemata in ulcerative colitis; Gut 1962 3: 312-314
3. Lee FI et al. A randomised trial comparing mesalazine and prednisolone foam enemas in patients with acute distal ulcerative colitis; Gut 1996; 38: 229-233
4. Dignass A, et al. Second European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Current management; Journal of Crohn's and Colitis (2012), http://dx.doi.org/10.1016/j.crohns.2012.09.002
5. Carter MJ et al. Guidelines for the management of inflammatory bowel disease in adults; Gut 2004; 53(Suppl V):v1–v16. doi: 10.1136/gut.2004.043372
Competing interests: CR has research funded by Olympus, Fuji and Cook. JCM is on the advisory boards for Abbott and Genetech. SP has received payments form Warner Chilcott, Ferring, Shire, Astra Zeneca for chairing meetings, advisory boards and attending conferences. He also has research funded by Fuji.
South Tyneside NHS Foundation Trust, Harton Lane, South Shields, Tyne and Wear, NE34 0PL
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+We thank Drs Price and Thachil for taking the time to read our article, and for providing further helpful insight into the detailed management of ulcerative colitis. We agree with all their points. As we were tasked with writing a contemporaneous evidence-based review, with a particular emphasis on pharmacological therapy, we were not able to cover all aspects of the aetiology, epidemiology, diagnosis, and management of the condition.
Competing interests: ACF has received speaker’s fees from Shire pharmaceuticals and MSD. PM has received speaker’s fees from Shire pharmaceuticals. SBH: has consulted for Shire, Ferring, Abbott, Warner-Chilcott, and Janssen, and has received speaker’s fees from Ferring, Abbott, Warner-Chilcott, and Janssen.
Leeds Gastroenterology Institute, Leeds, UK, 4th Floor, bexley Wing, St. James's University Hospital, Leeds, UK
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+The authors state that infectious causes will have been excluded by 'stool examination'. They need to indicate how many stools are needed and whether the laboratory they are sending them to has expertise in searching for all possible relevant pathogens, including parasites.This should be discussed with the medical microbiologist involved. Serology, particularly for amoebiasis and giardiasis, should be sent to a reference centre.
Competing interests: none
not applicable (retired), London NW11
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+In the excellent practice-oriented article on ulcerative colitis, Ford and colleagues overlooked the role of thrombosis prevention in acute flares of ulcerative colitis. Thrombosis as a triggering factor for this condition is well-established [1]. The link between inflammation and coagulation in inflammatory bowel disease, as a whole, is being explored in the trials where heparin is being tried to modulate the patient outcome [2]. Beyond the benefits at the molecular level from influencing mucosal inflammation, anticoagulant treatment is paramount in any flare-ups since ulcerative colitis is a very strong risk factor for thrombosis, even in the absence of hereditary thrombophilia [3, 4].
In recent years, another dilemma has been raised where pregnancy morbidities are frequently noted, despite successful outcomes from the continued use of 5-aminosalicylates. Whether thrombosis is responsible for the high risk of pregnancy complications has not been systematically studied, although antithrombotic prophylaxis should be given serious consideration to prevent venous thromboembolism in this setting, due to multiple risk factors of inflammatory disease and the procoagulant pregnant state. It will be an interesting prospect whether routine use of such prophylaxis may translate to better pregnancy outcomes.
References
1. Danese S, Papa A, Saibeni S, Repici A, Malesci A, Vecchi M. Inflammation and coagulation in inflammatory bowel disease: The clot thickens. Am J Gastroenterol. 2007;102:174-186.
2.Scaldaferri F, Lancellotti S, Pizzoferrato M, De Cristofaro R. Haemostatic system in inflammatory bowel diseases: new players in gut inflammation. World J Gastroenterol. 2011 Feb 7;17(5):594-608
3.Miehsler W, Reinisch W, Valic E, Osterode W, Tillinger W, Feichtenschlager T, Grisar J, Machold K, Scholz S, Vogelsang H. Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism?. Gut. 2004;53:542-548.
4. Grainge MJ, West J, Card TR. Venous thromboembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet. 2010 Feb 20;375(9715):657-63
Competing interests: None declared
Manchester Royal Infirmary, Oxford road, Manchester, M13 9WL
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+This excellent paper summarizes much of general importance about the current management of UC. However it also highlights the major failings of chronic disease managment in the current purchaser-provider split NHS and this will only get worse with the upcoming changes.
The authors rightly highlight the importance of prevention of opportunistic infections with immunisations. This is something I have been trying to do for many years, even before the European guidelines strongly endorsed this practice (1).
There is often a small window of opportunity before starting steroids or immunomodulators in UC to effectively and safely provide vaccinations. Yet the patients cannot seem to get this done. Most local general practioners will not do it because these are not listed the Green book(2), and/or the local Drug and Therapeutic Groups have not positively endorsed the useage.
It would be easy enough to give these in the secondary care enviroment, in fact judging by my experience in travel clinics, these could be a nice income generator for the Trust. However, this is not allowed by the Trust because the purchasers have not commissioned this particular service.
There is the dilemma, if a comprehensive service for a chronic disease like UC is commissioned, surely it should include all facets, such as prophylactic immunisations? Or if this is specifically excluded from the secondary care pathway, then surely by default it is a primary care activity?
It seeems we are getting further away from a genuinely seemless service for chronic diseases, like ulcerative colitis.
1.European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. Rahier et al. J Crohns Colitis. 2009;3(2):47-91.
2.http://immunisation.dh.gov.uk/category/the-green-book/ (accessed 9/02/2013)
Competing interests: None declared
Norwich Medical School, University of East Anglia, Norwich
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