Ulcerative colitisBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f432 (Published 05 February 2013) Cite this as: BMJ 2013;346:f432
All rapid responses
This clinical review by Ford, Moayyedi, and Hanauer (2013) presented fairly recent data on ulcerative colitis. This included a definition of the illness, its etiology, clinical features and associated symptoms, its pathophysiology, diagnosis, prognosis and treatment modalities.
I found this study to have a well organised and detailed summary for each subcategory presented above. All of the evidence for each treatment modality was clearly expressed while incorporating the statistical data to reinforce the conclusions obtained from the various studies. As reported by Fedorak, Wong, and Bridges (2010), the incidence of inflammatory bowel disease is at a rise in Canada. Furthermore, recent data by Ananthakrishnan (2015) also suggested an increase in prevalence in Europe and Canada. As a result, the information presented in this clinical review is substantial for evaluating the appropriate treatment modalities for all patients coping with ulcerative colitis.
It would have been interesting to also mention other treatment options which have shown varied effects on remission rates for patients with ulcerative colitis. One disadvantage was that no experimental treatment options were explored or mentioned in this clinical review. For example, the use of methotrexate as a maintenance treatment option for patient with ulcerative colitis has shown beneficial signs of remission with a clinical response of 30-80% obtained from an uncontrolled retrospective analysis (Herfarth, Osterman, Isaacs, Lewis, & Sands, 2010). Adding these additional treatment modalities could have enriched the clinical review presented by Ford et al. (2013)
In addition, standard dosing for the different pharmacological treatment options could have been incorporated in order to inform the readers which dosages produced the specific outcomes.
Overall, this article gives readers an accurate description of ulcerative colitis and all treatment modalities currently available with supporting evidence. The etiology of the disease has not been identified with significant evidence. I look forward to fully understanding the root cause of this unfortunate illness and how prevention can be achieved.
Ananthakrishnan, A. N. (2015). Epidemiology and risk factors for IBD. Nature Reviews: Gastroenterology & Hepatology, 12(4), 205-217. doi:10.1038/nrgastro.2015.34
Fedorak, R. N., Wong, K., & Bridges, R. (2010). Canadian Digestive Health Foundation Public Impact Series. Inflammatory bowel disease in Canada: Incidence, prevalence, and direct and indirect economic impact. Canadian Journal of Gastroenterology, 24(11), 651-655.
Ford, A. C., Moayyedi, P., & Hanauer, S. B. (2013). Ulcerative colitis. BMJ : British Medical Journal, 346. doi:10.1136/bmj.f432
Herfarth, H. H., Osterman, M. T., Isaacs, K. L., Lewis, J. D., & Sands, B. E. (2010). Efficacy of methotrexate in ulcerative colitis: failure or promise. Inflammatory Bowel Diseases, 16(8), 1421-1430. doi:10.1002/ibd.21246
Competing interests: No competing interests
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.
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.
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.
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
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 . 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 . 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.
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: No competing interests
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: No competing interests