A Personalized Approach to Care

We work closely with each patient to develop ongoing, effective treatment plans that improve and maintain overall health and nutrition while minimizing side effects and relieving the discomfort and stress of inflammatory bowel disease. 

When we talk about taking care of people with inflammatory bowel disease, we talk about obtaining and achieving certain goals. Our first goal is clarification of the diagnosis. Now this doesn't mean just making sure we know whether somebody has inflammatory bowel disease, or they don't have inflammatory bowel disease. That's obviously very important.

And it doesn't even necessarily mean clarifying whether somebody has what we call, Crohn's disease. Or that they have ulcerative colitis. It actually has to do with a lot more. It has to do with understanding which parts of the bowel are inflamed, and which parts are not. It has to do with how severe the inflammation might be.

And very importantly, it has to do with also understanding whether the other organs that might be involved, like the joints, or the liver. If they're involved, understanding more about what's going on with them. A very important part of diagnosis in inflammatory bowel disease, is also making sure that the amount of inflammation we're seeing, adequately explains the symptoms that the patient is experiencing.

Some patients have a lot of symptoms, but only a little inflammation and that doesn't make sense, and we need to clarify it. And other patients have a lot of inflammation and not too many symptoms. So we need to rectify and justify all those different elements of the diagnosis. The other part of the diagnosis has to do with understanding other factors.

Like laboratory values, smoking history, family history and there's a variety of other factors that we pull together. Once we clarify the diagnosis, we can then talk about the prognosis, or what's likely to happen to the patient over time. So we know, for instance, that people who are diagnosed younger, have an increased risk for needing a surgery, or having problems later.

So if we know that, we might be able to choose specific therapies and do a different approach to therapy, than we might have done otherwise. And there's a variety of other examples that we could use. The second major goal of approaching patients with inflammatory bowel disease is very important. And it's called induction of remission. Induction of remission refers to turning off the inflammatory process.

That means turning off the inflammation, so that the bowel can restore itself to its normal state. And patients can return to feeling well. Our goal in induction of remission is to get a patient feeling back to the way they might have felt before they even had the disease. That really is an important goal.

And you can't move on to the next goal of treatment until you successfully achieve induction of remission. An example of induction of remission for patients with ulcerative colitis, would be that you don't have any more urgency. You're having formed stools, there's no blood. There's no waking up at night with bowel movements.

And you're able to distinguish what might be coming out from below. In other words, your rectum can sense whether it's gas or something else. And an example for Crohn's disease, would be that you're not having pain any more.

The diarrhea, if you have it, is gone. And some of the other symptoms that people experience, like having abdominal pain, that cramps when they eat. Or having joint pain that goes along with this, are also gone. So those are the types of things we focus on. But we've now moved to another level to even make sure we're doing this better.

And that is, making sure that we can actually show that the inflammation is completely turned off. So the patient feels well, we're very happy with that. But making sure the labs are normal. If it's a child, that their growth and development is restored. And we use a variety of other markers of inflammation, to make sure that we're actually achieving more of a chemical or biochemical control of the disease.

Then we move on to the next goal. The next goal is very important, and that's called maintenance. Maintenance is all about preventing the disease from coming back. Some people think maintenance is about taking medicine to suppress symptoms every day. But in fact, maintenance of remission is about preventing relapses over time. Or what patient's might call flares.

Prevention of relapse over time, means taking the appropriate dose of a medicine that's safe to be taken, that will suppress or prevent you from having reactivation of the inflammatory condition. Successful maintenance changes the natural history of the disease. Maintenance therapy should be steroid free. We don't want steroids on-board when people are in maintenance phase.

And maintenance therapy should be safe and tolerable. Meaning, the patient's willing to take it. It's available to be taken, and it's obviously safe to be used long term. As important as it is to be in maintenance phase and to understand why you're taking medicine, it's very important for people to understand that we're also learning new ways that we might approach maintenance.

Where we can adjust the doses of medicine over time. Or even think about changing the medicine, or removing some therapies over time. But we must continue to acknowledge that Crohn's disease and ulcerative colitis are chronic conditions. And therefore, maintenance therapy is really necessary.

When we successfully have somebody in maintenance phase of their therapy, we can then talk about other things. Like preventing complications from the disease, and thinking about how we do cancer prevention. How we focus on preventing surgery or repeat surgeries. And how we think about preventing such things, as vaccine preventable illnesses.

We use vaccines to prevent infections. We monitor people to make sure their medicines are working properly, and that they're not having side effects. And we can really focus on quality of life issues, like, what's the most convenient way we can deliver the medicine to the patient? And how can we keep them well and achieve their goals?

Whether it be to complete college, or go on to the next phase of their professional career. Or get married, have children, et cetera. So we work one, by one, through these goals, to get our patients under good control. And that's how we try to achieve this with our patients.

How is IBD treated?

IBD is a chronic disease that can usually be controlled with the appropriate medicine. Patients experience flare-ups (when symptoms are present) that are followed by periods of remission (when symptoms are not present). Although there is no cure for IBD, the goal of treatment is to help patients achieve remission, avoid relapses and have the best quality of life.

Our IBD team feels that, in most cases, continuous treatment is more successful than periodic intervention during flare-ups. To ensure we offer comprehensive care, our physicians meet weekly to collaborate on cases, share viewpoints and weigh the pros and cons of different IBD management plans.

Hi, I'm Dr. Russell Cohen, professor of medicine and director of the Inflammatory Bowel Disease Center here at the University of Chicago. Today, we're going to discuss reasons why doctors choose certain medicines for patients with inflammatory bowel disease. One of the first questions I always ask my patients is what medicines have you already been on and what has been your experience with them? Have they worked for you? Have you had any side effects? Were you on too low a dose, too high a dose? Or maybe things had just worked out fine?

Many times when we look at different medicines, we determine what medicine are we going to use to get somebody better as we say induce remission, and then what medicines are we going to use to keep the patient better, which is maintaining the remission? Both Crohn's disease and ulcerative colitis and associated conditions are chronic relapsing inflammatory diseases. So it is important not just to get someone well but to keep them well almost always with medications. Sometimes the choice of medicines depends upon whether the patient can or will take pills, versus medicines that are given by a shot, or medicines that require an intravenous.

Some patients simply can't do one of the other and end up having a preference for a particular delivery. For example, you might think that patients would not want to give themselves a shot but actually some people don't like taking pills and they feel that the shot medicine might work better. Some people prefer an intravenous medicine because the medicine is delivered by a health care professional in a controlled setting. But it's also more inconvenient because that person then has to travel to the location and wait while the medicine is mixed, and then wait for it to go in as well, and sometimes even has to be monitored afterwards too. Some medical conditions, such as diabetes, may limit our ability to use medicines, such as steroids.

Other factors that we consider are whether you've had infection before, whether you've had any type of cancer or tumor before, and sometimes even whether you are someone who'd be very susceptible to a side effect from a medicine, perhaps due to your family's history with that medicine as well. Well I hope this has been helpful introduction of some of the things that go through our mind when choosing or helping you choose the best medicine for your disease. This is Dr. Russell Cohen. Thank you for joining me today.

Treatment Options for Inflammatory Bowel Disease

Medications typically are the first line of treatment for Crohn's disease and ulcerative colitis. There are several types of drugs that can help control inflammation in the digestive tract. While these medications do not cure inflammatory bowel disease, they can alleviate or eliminate symptoms and lead to remission. The team at UChicago Medicine has access to the latest medical advances in IBD care and will work with patients to create a personalized plan that is best for the course of their condition. We are one of a handful of research centers testing IBD treatments and our physicians have extensive experience with even the newest medications before they are available to other institutions.

In some cases, surgery may be necessary. Patients with Crohn's disease may need surgery for strictures, fistula and/or bowel obstruction. Some patients with Crohn's disease or ulcerative colitis may eventually require complete removal of the large intestine.

We know you will likely have a lot of questions about the best treatment plan. Our team of gastroenterologists and surgeons work together to provide you with all of the information you need. Many of our IBD surgeons specialize in minimally invasive procedures, which reduce scarring and help patients heal and return to activities faster than traditional surgery.

Your physician may discuss dietary changes. Although there is no data to suggest that diet causes or cures IBD, reducing or increasing intake of certain foods may help to decrease symptoms. We also make sure you are getting the appropriate nutritional support to reverse any dietary deficiencies and provide sufficient nutrients.

With so many available treatment options for inflammatory bowel diseases (IBD), patients and caregivers must make the choices that best fit their needs. Join David T. Rubin, MD, for an educational webcast that will provide in-depth information on IBD treatments and the resources needed to make informed decisions about managing IBD care.

Living with IBD

We understand that IBD is a complicated disease that can have a broad impact on quality of life. Our IBD360TM initiative provides patients with all of the care they need for their complex illness. Through this program, we facilitate parallel visits with experts in rheumatology, dermatology, gynecology, psychology and social work as well as our clinical trials group. In addition, we offer specialty care to address the challenges facing teenagers and women with IBD.

IBD Specialty Programs

Our Transitional IBD Clinic — one of the few in the country — is designed to meet the unique needs of teens and young adults ages 15 to 22. The clinic is a bridge between pediatric and adult care that provides the tools and support that our young adult patients need in order to take a more active role in IBD management. For patients who attend out-of-state college, we help identify a local physician with whom we can partner to provide ongoing care.

Crohn's disease and ulcerative colitis can affect women differently than men. Our new comprehensive Fertility, Pregnancy and Sexual Function Program for women with inflammatory bowel disease brings together specialists from a variety of disciplines, including obstetrics and gynecology and gastroenterology, to address these challenges. We focus on helping women manage their disease before, during and after pregnancy.

VIDEO TRANSCRIPT (PDF)

Understanding Biologics and Inflammatory Bowel Disease

Biologics are used to treat inflammatory bowel disease because they help your immune system target certain proteins in your body that cause inflammation.

Hi. I'm Dr. Russell Cohen, professor of medicine and director of the Inflammatory Bowel Disease Center here at the University of Chicago. Today we're going to discuss how do we choose which biologic therapy to start our patients on with inflammatory bowel disease. Currently, there are two main classes of biological therapy. The anti-tumor necrosis factor, or anti-TNF agents, and then the anti-adhesion molecule agents. These are very different approaches to treating patients with inflammatory bowel disease. The anti-TNF agents, which you might know as infliximab, or adalimumab, or certolizumab, or golimumab, generally work rather rapidly in patients with inflammatory bowel disease. And since they do affect the rest of the body too, are very helpful if patients also have joint pain, maybe skin problems, or other related problems to their bowels.
The second group, the anti-adhesion molecule antibodies, which are natalizumab and vedolizumab, are gut-specific only. So if the only problem is in the gut, that might be an option we choose. However, their onset of action is often slower than the first agents that I discussed. If a patient is sick, unless we can get them better initially with another therapy, it might be a better option for us to choose the first set of therapies I mentioned, the anti-TNFs, since they do work faster in many patients. Sometimes the decision is based upon whether a patient has had a previous therapy, perhaps a biologic therapy, whether they've had an allergic reaction to it, or whether they have, or have recently had, an infection, or even a cancer.
Patients who have active infections are encouraged first to have the infection treated before starting a biological therapy. This is especially true with the first group, the anti-TNF therapies, since they do affect the rest of the body and can impact that body's ability to fight off another infection. There are rare instances where we may have a patient, for example, who has a high risk for a certain infection such as tuberculosis, perhaps because of their background, or perhaps because of travel plans. In those patients, we might choose to use an agent such as the second group, the anti-integrin antibodies, because they don't seem to need for us to require first clearing of tuberculosis or testing for tuberculosis prior to starting therapy. Although in reality, if there's ever any suspicion of an infection, be it tuberculosis or other, we would diagnose that and treat that before starting therapy.
The final reason to choose a biologic therapy might be dictated by your insurance company. Often they will have a preferred therapy that, if it is medically reasonable, it's much easier and faster for us to go with that one. However, I do want to make it clear that if it's not medically reasonable, then we would insist on you getting the therapy that we discuss with you and agree to. This is Dr. Russell Cohen. Thank you for joining me again today.

VIDEO TRANSCRIPT (PDF)
VIDEO TRANSCRIPT (PDF)
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New guidelines for treating patients with ulcerative colitis

A team of experts, led by Dr. David Rubin, established new guidelines on diagnosing and managing ulcerative colitis. The guidelines are aimed at helping patients experience sustained periods of remission from inflammatory disease while relying less on traditionally used steroids.

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