Advances in IBD Treatment: Expert Q&A

Hello and welcome to At The Forefront Live. Inflammatory bowel disease is a painful illness that involves an abnormal response from the immune system. This can lead to damage of the lining of the digestive tract, causing inflammation, alteration, severe abdominal pain and more.

UChicago Medicine is one of the few research centers in the country testing new IBD treatments. Director of the UChicago Medicine IBD center, Dr. Russell Cohen, and advanced practice nurse, Ashley Perkovich, join us for a live Q&A to discuss the latest advances in IBD treatment. And as always, we'll take your questions live. That's coming up right now on At The Forefront Live.

And as always, we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's have each of you introduce yourselves and tell us a little bit about what you do here at UChicago Medicine. And Dr. Cohen, we're going to start with you.

Terrific. Thanks, John. And thank you all for joining us today. So I'm Ross Cohen. I am the director of the IBD center, Crohn's disease and Ulcerative colitis at the University of Chicago.

And I'm also a professor of Medicine at the Pritzker School of Medicine at the University of Chicago. I wear many hats. But probably for the purposes of this presentation, that would suffice for this point.

And Ashley, let's go to you now.

Hi, everyone. My name is Ashley Perkovich. I'm a nurse practitioner at the Adult IBD Center here at University of Chicago. Currently, I see patients in person and virtually for their routine follow up IBD care.

So Dr. Cohen, we're going to start off with a very general question and then we'll get into the more specific questions. We want to remind our viewers also, that if you have anything that you want to ask our experts, just type them in the comments section.

We'll get to as many of those questions as we possibly can over the next half hour. But let's just start off with broad, general what is IBD and how does it affect the body?

Well that's a great question, John. So many people may have heard the term Crohn's disease or Ulcerative colitis. They are two main types of inflammatory bowel disease.

As the name implies, it's inflammation in the intestines of the body. It is often considered to be an inflammatory response, rather than an autoimmune response. But in reality, what's happening is your body's immune system that's supposed to be protecting you is actually attacking your intestines.

People who have ulcerative colitis into colitis will only have inflammation in the colon or the large intestine, they're the same. While People who have Crohn's disease can also only have it in the colon. That'd be Crohn's colitis. But more commonly, also have it in the end of the small intestine, which is called the Ilium.

There are some people who have it in the mouth, or esophagus, or stomach, or all the way down to the anus. But those are the most common locations.

Dr. Cohen, I want to point out, you're actually in our River East facility today. Because you travel around and see patients in various facilities. That's a beautiful, beautiful new center. And certainly, if people need care, that's a great place to go get it. Ashley, can you tell us a little bit about diet and the important role that diet plays in reducing inflammation? Can that help?

Yeah. It's a really good question and one that's asked pretty frequently. So there's no known diet, unfortunately, that will help decrease the inflammation associated with IBD. Many patients do report though, that by following a specific diet, perhaps the simple carbohydrate diet, or perhaps by eliminating certain things from their diet, can help with symptoms such as bloating or cramping.

So we encourage patients, if they find a diet that's helpful for them, that they can follow it. But we ask them to do it in conjunction with medical therapy. Patients that happen to have active inflammatory bowel disease, so they're currently exhibiting a flare. Specifically in their small intestines, or let's say that they have a known stricture or a narrowing of the bowel, or have had bowel resections before. We ask that they follow a low residue diet.

Avoiding things like nuts and seeds. Because those can actually get stuck in the narrowed areas of the bowel. And actually, we currently have a clinical trial looking at the effects the Mediterranean diet has in Crohn's disease. So to be continued on that.

That's great. And Dr. Cohen, can you talk to us a little bit about clinical trials? Ashley just mentioned one. That's a big part of what we do here at UChicago Medicine.

And in my mind that's, an important, I think, kind of a differentiator with the work that happens with your team and the other folks that work here at UChicago Medicine. Because there are those clinical trials and there is that research that happens at this facility.

And you bring up a great point. You know, our motto is, we're at the forefront. And with clinical trials, you clearly are. We are one of the world's leading centers in clinical trials in Crohn's and colitis.

And you also brought up the point that currently now, we are coming to you. So for example, I'm in our River East office, which is right off Michigan Avenue, right by Navy Pier. Many of my other colleagues come here too.

I also go to Orland Park Illinois. We have a beautiful center at 143rd and La Grange Road. We're also in Hyde Park. We do procedures in Tinley Park and procedures right off of Michigan Avenue. We're 900 North Michigan, right by the famous shopping area too.

So myself and many of the other practitioners now will go to multiple sites. So it's very, very easy for you to get in to see us. One of the things, as John mentioned that we offer, are novel clinical trials. These are new medicines. Some of them aren't even on the market yet.

Or some may be on the market for other conditions that we are testing in people with Crohn's disease and ulcerative colitis. Some of them are diet, as Ashley mentioned earlier. We even have some that are actual procedures that are done for people who may have what's called fistulas of Crohn's disease.

So we have an ever changing menu, if you will, of options that very few, if any other place can offer. Certainly not available in this area to the extent that we offer. And even throughout the country, it's hard to find a place that would have as many opportunities as right here at the University of Chicago.

So Dr. Cohen, let's talk about biologic medication. That's something we've heard a little bit about. And something that a lot of viewers are curious about. What are the risks and benefits of this type of treatment?

Well, sure. You know, people shouldn't be afraid of the biologics. So biological therapy, insulin is a biological therapy. Growth hormone is a biological therapy. Many people are them and don't realize it.

But when we talk about it, we're talking about really breakthrough, what are called, monoclonal antibodies, in most cases. That have revolutionized the treatment, of not just Crohn's disease and all ulcerative colitis, but also rheumatoid arthritis, psoriasis and some other inflammatory conditions. The nice thing about these biologics is, contrary to the commercials, they're actually far safer than the older immune suppressant medicines that we're using.

True, they are given right now mostly by IV or shot. But that actually doesn't make them more concerning. They are, as I mentioned, safer because they don't suppress the bone marrow, for example, or interfere with certain pathways in the liver or other inflammatory areas that could cause problems.

So the new stuff, the biologics is not what you should fear. They are what you want to be on. The old stuff is basically chemotherapy. And we're moving from using chemotherapy for Crohn's and colitis, now to using safer biological therapies. Very few people have any problems with these medicines. And if they do, we can usually just switch you to something different.

Now this may be more than we can get into in 30 minutes. But what do biological therapies do? What happens in the body when somebody receives one of these therapies?

Well, sure. And you know, I do want to point out, that virtually all the biological therapies that are approved in the world for Crohn's and colitis were tested at the University of Chicago. So some of our patients are listening to this right now and they were the heroes that volunteered for these therapies.

Most of them work by blocking very inflammatory chemicals in your body that cause inflammation. Some of them actually prevent the white blood cells from leaving the bloodstream and entering the gut. Kind of prevent, almost locking the door so the white blood cells can protect you against other infections and things.

But they don't bother the gut. Some of them actually were learning better how they work. Because they have other properties as well too. So the important thing is that the therapies are very effective. They're very focused. And they really have changed many people's lives with these diseases for the better.

So Ashley, how can a person manage their symptoms without medication? Because I think a lot of times people-- they want to try to steer away from that if possible. Now we don't want to, obviously, give anybody any ideas that they shouldn't take medication if it's prescribed by a physician. But what are some things that people can do?

Yeah. That's a very good question as well. So I would say that, in order to keep your disease in remission and to prevent flare ups, you need to continue your maintenance medications. And you need to take them as prescribed. Meaning, the correct does and at the correct dosing interval, in order for them to work optimally.

If you are feeling well and you're perhaps considering whether or not you need as much medication, or perhaps whether or not you can decrease your dose or go down from to medications to one. Before doing that on your own, you really should discuss that with your gastroenterologist. But things outside of taking your maintenance medication to keep your disease under control, are doing things like getting your stress under control.

Through things like exercise, yoga, meditation. And also just by eliminating dietary triggers in your diet. Known things that can cause you to have issues.

You know, it's interesting. Because we always tend to talk about diet no matter what the condition or the disease state is. Because it does have an impact. The other thing we always talk about is smoking.

People should quit smoking. I don't know if that has any kind of an impact on IBD. Maybe it does. I don't know. But diet in general is just so important, diet and exercise to the health of an individual. And I would imagine you probably see that in your practice on a pretty regular basis. Dr. Cohen.

Well, yeah. I mean, as Ashley mentioned, these things are very important. And part of it, as far as the diet and exercise, is feeling good about yourself. Feeling well enough as you can do. Getting the adequate nutrition.

One of the nice things is that we offer nutritional assessments by a registered dietitian, for people who have more serious nutritional deficits. Part of our University of Chicago gastroenterology, hepatology and nutrition group is nutrition. We were the first World Center for nutrition.

And many of the top experts in the world trained here at the University Chicago. We can arrange for that too. Smoking is fascinating. So Crohn's disease and many inflammatory diseases are diseases of smokers. Over half of patients with Crohn's are smokers.

And when smoking used to be more prevalent, over 3/4 were. Ulcerative colitis on the other hand, is a condition of nonsmokers. In fact, most people who get Crohn's are colitis or first diagnosed in their 20s or so. But if you're diagnosed with all ulcerative colitis when you are, let's say, my age, which will remain undisclosed for the purposes of this presentation.

Often it's because that person around my age stopped smoking and they actually get new old ulcerative colitis. Now we don't use smoking to treat ulcerative colitis. But it is fascinating. And one of the ways that Crohn's and colitis differ is the impact of smoking.

Ashley brought up a good point about communication. It's really important that you can communicate with your medical team. And one of the wonderful things is that all of our patients are encouraged to sign up for what's called, My Chart. Where they can have direct communication with our staff about their medical issues.

Don't have to wait for the phone call back. Don't have to be teaching a class and getting an embarrassing phone call from a gastroenterologist And it really has made it very possible for you to get direct answers from the people who know it, rather than getting it from other sources.

You know, it's interesting you bring up My Chart. I'm a My chart user myself here, as not only an employee here, but a patient here at UChicago Medicine. And I can't stress how right you are with what you just said. It is an invaluable tool.

It's great to be able to communicate with your physician and your providers. It's just really, really helpful. That's another thing that, again, that we offer that is very helpful. The other thing I want to ask you, because I think this kind of gets into this area.

We're in this time of COVID right now and many people are worried about getting out. And we've talked about this on the program before. But I'd like to ask both of your opinions on this.

If people are worried about that, I know that this is a very safe place. But can you offer some words of reassurance to our viewers so that they realize too, that if they need treatment, if they need help, to certainly get that? And Dr. Cohen, I'll start with you on this one.

Well sure. Well first of all, we offer video visits. In case that people really can't do a video, it could possibly be by telephone. But ideally video visits for both new and established patients. And most people are taking advantage of that, as well as live visits when possible.

Our sites are intentionally set up so that there's very few people here. We all have the social distancing and masks in place. The only reason why I'm not wearing a mask is I'm in a conference room with the doors that are locked. And for example, Ashley, who usually is with me at River East, is not here today.

Because this way, we don't have too many people here. She's working remotely. So I'm seeing live patients and she's doing remote patients. So we have certainly prepared for this. People who are coming in for blood tests, we have them make an appointment to do so. So they're not all jamming into the laboratory. And this is also at or other off sites too.

Those sites are very safe, very clean. There's really nobody allowed in unless the people are supposed to be there. It is concerning, particularly if you have an inflammatory or immune condition, about the COVID outbreak. But we really want to make clear that the key is you staying well. You getting your medicines, staying on them.

Because that way you don't have to emergency go to a medical facility and possibly have an exposure. The other thing that's important is that if you had procedures that are scheduled. In GI we do colonoscopies, as you, unfortunately probably know. While they were on hold for a while, we are doing them.

Every patient gets COVID tested ahead of time. Nobody who has positive for COVID comes into the procedure areas. So we're extremely safe with that. And it's important to do that. And also for your other medical screenings. Because, unfortunately now, we're going to be seeing higher rates of breast cancer.

Because people who are not getting their mammograms. Colon cancer, because people aren't getting their colonoscopies. Prostate cancer people aren't getting their prostate exams. And things like that too. So yes, it was very scary in March and April.

But as you guys know, we're at the end of October. And the situation is not going to change dramatically in the very near future. So taking the right precautions, wearing a mask, doing hand sanitizing, six feet apart, you can continue going on with the important things your life. And medical screenings and appointments are certainly included.

Yeah. I think that's just such an important message that we really want to get out to viewers. You have to take care of yourself. Now more than ever, you have to take care of yourself.

And if you need medical treatment, please seek it. Because these are safe places to come to. And even what we're doing today, we're doing the entire program remote. The reason I'm not wearing a mask is because I'm all by myself in a room.

You all are at separate locations. See, there's nobody here. We don't even have a camera person in here. And the technical people that are in a completely different area. So we're trying to be very careful just from start to finish with what we do here at UChicago Medicine. And we've been pretty successful with it so far.

Ashley, have you'd been doing some of the video visits? If so, I'm kind of curious how that's gone. I've heard some providers even kind of liken them to the old practice of making house calls.

Yeah. It's actually been going really well. I think that now that, you're right, we are almost into November with COVID, there are going to be some positive things I think that came out of this. And perhaps being able to do a virtual visits will be one of them. It was a little challenging at first when it first rolled out and we had never done them before.

But now that we've been doing that for a few months. A lot of patients like them. They prefer them. You mentioned biologic therapies earlier. And Dr. Colin and I typically will see patients every three to four months and want to get labs every three to four months if they're on biologic therapy.

But right now, if they're doing well and their disease is in remission, and it's just kind of a routine follow up visit, then we're allowing them to do with virtual visits. Where we just kind of touch base via video. And then we have them come in at a separate time and get labs. But this has gone over very well, especially for our patients that drive a far distance to see us.

This has been very convenient for them. Of course, if you are flaring or if you are experiencing any disease activity or something new has come up, we will see you in person in clinic. But we're just trying to stagger things to keep everyone safe as possible. And overall, I think it's been going very well.

Great. Dr. Cohen, we have a few questions coming in for viewers that I'd like to get to if we possibly can. The first one-- Actually I'll do a two part-er. These are two questions from two different people, but we'll kind of put them together.

The first is how do you diagnose Crohn's or colitis? And the second one, are there pre-screenings for Crohn's or colitis?

Well sure. Well most people are diagnosed by a colonoscopy, which is a scope that's actually thinner than my finger. It really is, a little longer. That after you're sleeping, we go in through your bottom and go around the inside of the bowel.

Occasionally, there are people who in Crohn's disease, where it's only in the small intestine. You can't get to that very easily with a scope. So those people, we might need a CAT scan or MRI. Some people are diagnosed with scope into the stomach, through the mouth, esophagus, stomach.

That scope is thinner than my pinky, too. And I don't have big, fat fingers. So you guys should be happy about that. Typically, that's how it's done. Occasionally there are some people who need other ways to find it as well too. And then, sorry, what was your other second part of the question?

The second one is just if there are pre-screenings that are available that might detect?

Well Crohn's and colitis are not that common. And they most likely have onset in children, teenagers or early 20-year-olds. So if there is no family history, then there's probably no need for pre-screening.

But if you have a very strong family history, particularly for Crohn's, we just tell, make sure the kids are staying on the growth curve. There's no unexplained anemia. All kids are going to get diarrhea or constipation stomach pains.

But if it's a persistent problem, maybe have that investigated. And then moving forward, we really don't do pre-screenings. Because you either have it or you don't.

Sometimes we do have people who are going for colon cancer screening, typically around age 50. Although now it's back to 45 in some people. And they happen to find it incidentally.

Here's another interesting question from a viewer. And this deals with COVID. One of the treatments for COVID involves the use of steroids. Is that a problem for IBD patients?

Well that's a huge problem. So let's just make things very clear with COVID. People with Crohn's and colitis or other inflammatory diseases who are on steroids, you need to get your doctor to get you off the steroids. It's far safer for you to be on the biologic therapies or the other immune suppressants than to be on steroids.

We know this for a fact by very good databases and other information. Don't confuse that with very sick COVID patients hospitalized, perhaps in our intensive care unit, who they give high dose steroids to, to suppress the immune response. See those people, unfortunately the COVID has turned on the immune response uncontrollably. That's what usually does them in.

It's not directly the virus. It's the body's response to the virus. So in those patients, they actually, as you probably know, are giving high doses of steroids. It's a completely different issue.

OK. Interesting. So Ashley, what kind of signs should someone look for if they think that they're having a flare up?

So that can kind of differ depending on where the inflammation of the IBD is. So in somebody that has ulcerative colitis or Crohn's colitis, the inflammation is in the colon. So those patients may experience right red blood in their stool, urgency and cramping with bowel movements, some diarrhea.

Patients with, let's say, small bowel Crohn's disease, can have symptoms such as abdominal pain, weight loss, fevers, of course, diarrhea. So some of those symptoms can overlap between Crohn's and colitis. But if you're experiencing any of these symptoms, and they're persisting and perhaps worsening, and they've been going on for more than a couple of weeks, then you should definitely seek medical attention.

So Dr. Cohen, we've heard a lot about CBD and medical marijuana just in the past few years. What kind of impact do we see in this area from CBD or medical marijuana? Or is there one?

Well, I think that's an important question. Because a lot of people are asking that. While there was initially a lot of hype about-- and there is little difference between the medical marijuana itself, which is marijuana, versus the CBD oils or CBD products. Unfortunately, as times gone by, there have been repeated studies that have not shown this to change the actual disease, the inflammation in Crohn's or colitis.

Some studies have suggested it's worse with them. And there is a vomiting syndrome that many people can get if they're using marijuana chronically. Where they get pain and vomiting. It's called Cyclical Vomiting Syndrome. So there is a lot of side effects to these that are not helpful.

I think you should differentiate people who use CBD or marijuana for reasons that they feel good, it alleviates pain or discomfort, than actually treating the disease. So our approach is, if you want to use these therapies or other alternative therapies, discuss with us. But also, we would courage you not to get rid of the proven effective therapies. Often doing things together with communication has the best outcome.

So Ashley, I think a lot of times people will start feeling better no matter what the disease is and then they don't want to take their medications anymore. Talk to us a little bit about that and the dangers of doing that, particularly with IBD.

Yes. So unfortunately, there is no cure for IBD. Crohn's and colitis are chronic conditions that require routine monitoring for disease progression. And long term medication use in order to keep the disease in remission, and also to prevent flares and prevent disease related complications down the road.

Disease related complications down the road could include things, as I mentioned earlier, strictures are narrowing of the bowels. Where the inflammation over time turns into scar tissue. The bowel becomes less flexible. It narrows, down strictures down, and food can become stuck there, which can lead to bowel obstructions. A common reason for IBD patients to wind up in the emergency room.

Sometimes if they have a really tight or narrow stricture, that will require surgery or a bowel resection. And there are other unpleasant things associated with Crohn's Disease, such as fistulas and abscesses. So if you don't keep the information under control, you're putting yourself at risk of developing these complications down the road.

So Dr. Cohen, it risk of cancer increased because of IBD?

So people who have inflammation long term, are at higher risk. It's usually in the organ that the inflammation is located. So for example, ulcerative colitis, or Crohn's of the colon, over time does increase your colon cancer risk.

There is some data that suggests, just as Ashley was alluding to, that if you keep the inflammation under control, you actually may decrease your cancer risk. And that's important because, if you're a non-smoker, your highest risk overall in the population in America is colon cancer. So if you also have Crohn's or ulcerative colitis, you've even increase that risk.

If the Crohn's affects the colon. The ulcerative colitis always does. So now, you can potentially decrease the risk for your most common, most feared cancer, simply by adhering to the medicines. And sometimes people are afraid of medicines. They hear things on TV about rare risk of lymphoma or other cancers.

Your risk of lymphoma or from anything we give you is far less than your risk of colon cancer from having a potentially uncontrolled inflammation. One of the things that Ashley mentioned about the state of Crohn's and colitis, about it not being curable. Well, we're looking to change that. We actually do have some breakthrough research going on through my colleagues at the University of Chicago, who work with others around the world.

And many of our patients are part of these studies. When we do a colonoscopy, we get extra biopsies, we get extra blood tests. So we're actually probably going to change that line of it being lifelong. And people may not need medicines forever. But let us be the ones to tell you that.

That is great news. It sounds like we have some positive things coming. Well we're out of time. You both for great and shared a lot of really important information with our audience. We thank you. And thank you to our viewers for your fantastic questions.

Please remember to check out our Facebook page for a schedule of programs coming up in the future. Also, if you want more information about UChicago Medicine, make sure to take a look at our website, UChicagoMedicine.org. If you need an appointment, you can give us a call at 888-824-0200. And remember, you can schedule your video visit by going to the website. Thanks again for being with us today. And I hope you have a wonderful week.