Probiotic Studied in Pouchitis

Probiotic is a term that refers to good bacteria that are given to fight disease. Whatever the merits of the term probiotic, we finally have a study that was well done. The study publishedin the journal Gastroenterology was very clear: in a group of patients with the problem of pouchitis there was clear benefit.

I think those are excellent examples of what probiotics have the potential to do. I agree, the data on C. diff colitis looks most compelling to date. The editorial in Gastro this month was prompted by a study that was in the same issue, relating to the use of probiotics in pouchitis, the problem of inflammation in the small intestinal pouch created during ileoanal anastamosis after removal of the colon for ulcerative colitis. To put the horse before the cart, review of the article (by Gionchetti et. al. Oral Bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial) would seem in order.

The study looked at 40 patients with pouchitis all of whom were in remission on drugs. The drugs were then stopped and the 40 patients were then either treated with placebo (maize starch) or a bacterial product called VSL#3 taken twice a day continuously. The trial followed these patients for up to 9 months. In the placebo treated group patients started having relapses after a month, and then all 20 patients eventually relapsed over the next three months, about 2 relapsing each week. In the VSL#3 arm of the study 3 of the 40 patients had relapse over 9 months. Bacteriological evaluation showed that the germs in the stool changed over time with more bifidobacteria, lactobacilli, and strep. salivarius present. The did not subspeciate the bifidobacteria or lactobacilli, however. 

This is the first paper I have seen on bacterial supplementation which is randomized and controlled. As such, it porvides usable data upon which to make medical recommendations. The product used in this trial was shown to provide protection from relapse in the subgroup of patients with pouchitis in the setting of ileoanal anastamosis with chronic pouchitis who had been well controlled on drugs. 85% of patients had a prolonged benefit, compared to 0% on placebo. 

This study provides useful information because it is a controlled study, the patient groups are well described, and sufficient detail is provided to understand the expected benefits of the treatment. The study applies to those with pouchitis who were in remission on medications who took VSL#3. It shows that the bacterial treatment is almost as good as antibiotic treatment for maintenance of remission of pouchitis. (15% failure rate for bacteria versus 5% for antibiotics) The control group was interesting. Maize starch may not have been the best choice of starch. Maize contains certain types of starches that are not digestible by amylase. This means that patients on Maize starch will deliver carbohydrates to the lower intestine, or to the pouch in this case, which could potentially aggravate the pouchitis. Had they used rice starch this would not have been the case. However, the patients selected for the study were patients who were having a lot of relapses anyway.

VSL#3 is an unusual probiotic. It is comprised of 8 different bacteria. Also, they are at very high concentrations and have been freeze-dried. In animal and in-vitro studies single strain mixtures are not able to effectivly change the flora already present in the gut. Also, old studies of germ free animals show that putting in a single germ is generally lethal, but that a mixture of germs is beneficial. These results were the basis for formulating a mixed bacteria supplement. 

These issues raise doubts as to whether single strain bacteria would be as effective as multi strain mixtures. Two studies in ulcerative colitis in the past have shown no benefit with a single strain, but an open label trial suggests there may be some benefit to VSL#3 in UC.

Bacteria are very different from one another, and the diseases Crohn’s, UC, pouchitis, and c. difficile colitis are very different as well. While this mixture now has been shown to work in pouchitis much more needs to be done to determine how well other probiotics work in this and other diseases.

Sartor’s editorial was interesting. After reviewing the study he discussed other studies of probiotics. A strain of E. coli has been shown to have the effectivness of low dose masalamine in maintaining remission in UC. However, there are very few studies of benefits of probiotics. Whether all the strains that were used in this study are needed is not known, and whether other probiotics will help better is not known. Other approaches such as altering the carbohydrates delivered to the gut need to be studied. Sartor also reviewed proposed mechanisms – suppression of resident bacteria, stimulation of gut mucus, prevention of adherence of bad germs, and induction of gut immunity ( including affecting the type of immune response generated ). 

While the editorial was interesting, it did not give blanket support to the use of probiotics. It called for a carefull set of studies so we can understand what probiotics can and cannot do, and emphasized the fact that not all bacterial products are the same. 

If I had pouchitis that had previously responded to treatment I would consider the probiotic if I was one of those few patients with multiple relapses of pouchitis. However, I would expect to need to get the product from overseas and I would then need to take it twice a day forever. This in comparison to taking a course of antibiotics for 10 days three times a year. 

The interesting question is what to do if you are one of the patients that never responded to treatment. Potentially you immune response is different or your flora is different. Whether you would respond to VSL#3 is not known. It would be worth trying, but I would recommend a trial were done under medical supervision in case being such a special patient put you at risk for a flare or other complication when taking that mixture.

The study looked at 40 patients with pouchitis all of whom were in remission on drugs. The drugs were then stopped and the 40 patients were then either treated with placebo (maize starch) or a bacterial product called VSL#3 taken twice a day continuously. The trial followed these patients for up to 9 months. In the placebo treated group patients started having relapses after a month, and then all 20 patients eventually relapsed over the next three months, about 2 relapsing each week. In the VSL#3 arm of the study 3 of the 40 patients had relapse over 9 months. Bacteriological evaluation showed that the germs in the stool changed over time with more bifidobacteria, lactobacilli, and strep. salivarius present. The did not subspeciate the bifidobacteria or lactobacilli, however. 

It is possible for a physician to have feelings of loss when a patient improves

It is possible for a physician to have feelings of loss when patients improve.

The following is a post that was in the IBDList. Tom, the list moderator, added the comment at the end set off by brackets. The IBDList is a very valuable Maillist server for people interested in Crohn’s and colitis. If you like the sort of stuff you see here you would like to get the IBDList.

[Unfortunately, the IBDList stopped publishing a number of years ago – Ed.]

I had an interesting emotional response recently with a patient who was put into remission by surgery. This woman had her first attack of Crohn’sabout a year ago. She did well with steroids, almost came off prednisone after a slow taper, then went back on with a flare. On attempting to retaper she had another flare that turned into abscess. Surgery was required. The Crohn’s diseased tissue was very thickened, and perhaps it would neverhave healed with medical treatment.

I had seen her about once ever month or every other month during this time and I got to know her well. When she came in for the post op checkup she was off all her medications and doing very well, eating anything she wanted, all the visible steroid effects gone. While I should have been happy that she would not have to see me anymore, I found myself somewhat sad. It was feeling the feeling of loss.

Clearly what was happening was that the patient and I had been having success at dealing with the Crohn’s, and much of the satisfaction for me was the continued followup and advice that kept her going and the improvement she had following my advice. Knowing that I would not have to do that any longer was, I think, the basis for this. I think another aspect was that she came to surgery without my having given the advice. Having a patient go sour is disconcerting to the physician (certainly more so to the patient), but there is something of a feeling of “how dare that Crohn’s disease get worse just as I was dealing with it.” Part of GI training is to have the knowledge that surgery is not an evil to be avoided, but rather a tool to be used as needed.

I recall a post Tom put up on the IBDList a while back about havinga feeling of loss when in remission from IBD. The loss was in not doing the dietary restrictions and other things that had become routine, or familiar,to daily life.

Oh, the reason I put this up is that this is a list about IBD, living with it, and treatment of it. While I don’t think there is anything in this post that will affect what anybody does, it is the case that IBD affects many people besides the patient, and the physician is one of them.

Stephen Holland, M.D.

[ Thanks for an interesting perspective. I know that when a GI I had been seeing for a number of years retired, I missed him as a person as much as missing the physician. I never considered that he also might have feelings of the loss of day-to-day contact with his set of patients.

Diabetics these days often have a team of professionals helping themwith their disease since it affects so many areas of physical, emotional and spiritual life. In a way it is too bad that the medical community often doesn’t take a more all-encompasing approach to diseases such as IBD that are influenced by more than just the steriods or sulfa drugs. Maybe one day the insurance companies will realize that a combination of treatments, along with a healthy look at eastern or alternative medications and procedures can actually be cheaper than the most common methods of symptom-treatment or emergency-care medicine. -tom]


Update: 7/1/2019

I wrote this years ago. Now, about 20 years later, this feeling of loss doesn’t happen. But now patients are on immunosuppression, surgical procedures are followed by continued follow up for regular follow up. We realize there are so many things we do and look out for in our IBD patients that we don’t have patients that don’t need to see us after surgery. We continue to see our patients to keep recurrence rates low. It’s a different time now, with continued improvements in the outcomes of our patients with IBD


What to Do When You Feel Like Your Problem is a Burden to Others

Do you feel like a burden to your physician? Other patients do too. My feeling on the matter.

A reader of the IBDList wrote:

So much about having these illnesses cannot be communicated to your own physician in a 15 minute or even a 2 hour appointment. I have an excellent gastroenterologist, but he is extrememly busy and, unless I am in extreme distress at the time, I always hesitate to take up his time. And, of course, some of it just isn’t discussed because it is part of the illness. How do you convey pain? Or extreme embarrassment?

That’s why the list is so important. Sometimes, you just feel likethere is no one to tell or understand. Family members and friends can try to understand (or not), but this goes on so long and is so personal thatyou begin to feel that you are just making people feel worse, so you stoptelling anyone.

When I see comments such as this I have mixed feelings. I want patients to be able to express themselves and talk about their problems. However,I understand that as much as one may try to understand a patients condition,there is a world of difference in understanding the condition and actuallyhave suffered the illness. The physicians role is to understand the patient,the disease, and the treatments well enough to give good advice. Thus,the patient may give enough information to allow the physician to givegood advice, but that may well not be enough for the patient in terms ofemotional support.

Since physicians are limited to understanding the disease through theirpatients, I think it is important for patients with chronic diseases toseek out support groups. Sharing one’s problems with someone who has beenthere is important. Unless your doc has IBD, you probably cannot get thatlevel of understanding. Perhaps, even if you have a doc who has IBD, itis still not the same, for docs know the disease well enough that thereis perhaps less fear of the unknown, even if it is a happy little delusion.

That said, lets use some common sense as well. If you ahve a doc whonever has the time, it may be time to help that physician by decreasingtheir workload. Another doc who has the time may be what you need. Oneof the marvelous things about medicine is the variety of people you meet- both physicians and patients. The variety of needs that patients haveusually can be met by some physician out there. Another use of supportgroups, getting insight on what each doc in the community is like. 

So, if you feel you are a burdeon to your doc, it may be that you need a new doc. But if it is a matter of not being able to really communicate your burdeons, a support group might be very important for you to join. An online forum of support that I recommend is the IBDList. [The IBDList was a mail-list that was discontinued years ago. The reader is encouraged to browse the internet for on e of the many resources now available, and especially to look the the CCFA for local support groups – Ed.]

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

Celebrex for the treatment of Ulcerative Colitis – Not a good idea

There is a new antinflammatory drug out on the market named Celebrex. It has less side effects on the GI tract than typical arthritis drugs. Is it possible that it is safe in Crohn’s or Ulcerative Colitis? Well,no. See why in this article.

A reader of the IBDList asked recently if a new anti-inflammatory, Celebrex, would be useful in the treatment of Ulcerative Colitis.  The analogy of sulfasalazine, another drug with a salicylate component was offered as a rational to try it.

Crohn’s and UC are different from arthritis.  Some experience from the past is interesting in this regard.  A chemical in the body called arachidonic acid is converted by a series of enzymes into several chemicals that are part of the signaling system for inflammation. Two class of chemicals, prostaglandins and another, leukotrienes, are of particular interest inIBD.  It turns out that prostaglandins are blocked by drugs like aspirin,Motrin, Nuprin, and other similar drugs.  However, the mesalamine drugs (sulfasalazine, Pentasa, and others) block leukotrienes.

Clinical experience has shown that Motrin and its cousins can actually make UC and Crohn’s worse and cause flares, while mesalamine is beneficial. This clinical observation shows that leukotrienes are an important cause of inflammation in IBD, and prostaglandins are protective.

A new development in arthritis research is that prostaglandins are made by two enzymes, cyclooxygenase-1 and cyclooxygenase-2 (COX-1 and COX-2). It has been found that prostaglandins made by COX-1 protect the stomach from injury, while COX-2 products are important in arthritis inflammation. A new drug on the market, Celebrex, (a.k.a. celecoxib) blocks COX-2 but not COX-1.  It was predicted that this drug would be effective in arthritis and cause less injury to the stomach.  Animal studies and human studies have borne this out.

The natural question for IBD researchers – could a COX-2 inhibitor be beneficial in IBD.

To evaluate that question and not put patients at risk, Brian Reuter at the University of Calgary in Alberta, Canada, gave the drug L745337( a drug similar to celecoxib ) to rats which had colitis induced by an enema of TNBS.  (This is a standard animal model of colitis). The results of the experiment were that the colitis was much worse in the rats given the COX-2 inhibitor.  In fact, it was even worse than giving Naprosyn to the rats, which was also done in the experiment.  Additionally, giving etodolac, an NSAID which turns out to be somewhat more specific for COX-2 than the run of the mill NSAID, was almost as bad as the pure COX-2 inhibitor L745337.

These results lead me to recommend against giving Celebrex to anyone with IBD.  It is interesting that the more selective the drug was for COX-2, the worse the rats did.  Certainly, there are other models of IBD, and it is possible that human UC or Crohn’s will act differently at times than the animal models. However, I’d much rather see the animal studies before trying the drug in people.  This is also a good exampleof how animal studies are beneficial.

Heparin for the Treatment of Refractory Ulcerative Colitis: Results of a Controlled Trial

A trial of heparin in ulcerative colitis has been completed. Read about the results . (I am proud to have participated in that trial.) I previously wrote about findings at previous DDW meetings. Here is an overview and several abstracts about heparin in IBD that provide background information: Heparin in UC or Crohn’s?

I have reported previously on the use of heparin in Ulcerative Colitis.  A trial of heparin versus placebo wasrecently done.  The study was organized by Dr. Korzenik, now at WashingtonUniversity School of Medicine in St. Louis, MO.  I ran one of thesites that participated in the study.  The results of the study wereeagerly awaited.  The results of the trial were recently reportedat a session of Digestive Disease Week, a major international meeting thatI attended in Orlando, Florida.  Following is the abstract as published,with notes afterwards that I added.  The short answer is that it works. Read on for details.

Korzenik J, Bitton A, Robert M, et al.A multi-center, randomized, controlled trial of heparin for the treatment of ulcerative colitisGastroenterology 1999, 116:A752.

Background: A series of open-labeled trials suggest a benefit of heparinfor the treatment of Inflammatory Bowel Disease (IBD). No prospective randomizedcontrolled trials have been performed. We report the initial data obtainedfrom a large multicenter controlled trial of heparin therapy for the treatmentof moderate to sever ulcerative colitis (UC). Aims: To assess safety andefficacy of heparin in the treatment of active UC. Methods: Subjects wereenrolled with moderate to severe ulcerative colitis having four or morestools/day. Permissible concomitant medications included mesalamine, steroidsand azathioprine/6-MP for specified durations prior to enrollment. Subjectswere randomized (1:1) to saline injections or standard porcine heparininjections at 10,000 units subcutaneously (sq) bid for 6 weeks. In thoserandomized to heparin, the dose was adjusted by an unblinded observer to10,000 units sq tid for patients whose appt remained below the upper limitof normal. A subgroup (20%) of subjects randomized to placebo receivedtid saline injections. Randomization was stratified by extent of colitis(left sided vs pan – colitis) and by use of steroids. Patients were monitoredwith weekly aPTT and twice weekly CBC. Efficacy was determined by clinicalassessment of stool frequency, frequency of bloody stools, patient globalscale, physician global scale, sigmoidoscopic and histologic assessment(at week 0 and end of week 6). Failure was established by an increase inexisting medications or need for additional medication. Decrease of hematocritby 6 points or decrease of platelets below 100,000 was also criteria fordiscontinuation. Results: 70 subjects were enrolled at 9 sites. No severe adverse effects were observed in any subject. One subject was prematurely discontinued because of a decrease in hct of > 6 points but was in remissionat the time with no evidence of bleeding. Three patients noted a transient increase in rectal bleeding though not clinically significant and wereable to continue their involvement. One patient developed a psoriasiformrash at the injection sites. Enrollment has been completed, but the trialhas not yet been unblinded. Conclusions: 1) The use of heparin is safein the setting of moderate to severe ulcerative colitis. 2) Several subjects are completing their involvement at this time. Data for clinical efficacy will be reported after the trial is unblinded and will be available shortly.

At the conference the results were further detailed.  The majorresult was that the remission rate was 42% for patients on heparin, 20%for control patients.  It should be noted that these patients wereall not responding to regular therapy, so heparin was started only latein the course of their UC flare.  There was no significant increasein bleeding rates.  Patients that did respond all started to respondby three weeks.  One issue that was discussed was that the heparinwas given subcutaneously rather than intravaneously.  This was done because it was an outpatient study.  Since heparin given subcutaneouslymay make different fractions of the heparin available differentially, itis possible that IV use is more effective.  Note, also, the placeboresponse rate.  20% is somewhat low for a placebo response rate, showingthat these were chronically ill patients.  Nonetheless, 20% of patientsdid go into remission with just another month of their treatment withoutheparin.  This shows the importance of a placebo controlled trial. Had the control group not been included a result of just 40% response mighthave been believed to be placebo alone.  The placebo group shows that the response was real.

The information here is from an oral presentation.  These results have not been published in a journal and have not been carefully reviewed by outside experts.  A number of the results described in preliminary form do not turn out to be true.  The usefullness of a preliminary report is for early distribution of results and for feedback to the author before publication.  Due care needs to be exercised when acting onpreliminary results.

Concerns Regarding the Use of Nonprescription Drugs in Crohn’s and UC

The nature of Crohn’s and Colitis is not known. I think this is one cause of patients using nonprescription drugs, often misnamed nutritional supplements. A reader of the IBDList asked my opinion of Salmon Oil after reading the article on this page regarding Purepa. My reply was really a discussionof these unregulated drugs, Concerns Regarding the Use of Nonprescription Drugs in Crohn’s and UC.

A reader asked:

Dear Dr. Holland:

As the mother of a 22-year old son with Crohn’s, I have valued your input on the IBDList for the past year. Today was my first visit to your IBD page.

In addition to being on Asacol, I have had my son on a variety of other natural “remedies” including cat’s claw, aloe vera capsules, vitamins and salmon oil.  After reading your article about Purepa, I am anxious for him to give it a try.  Do you feel this would have a greater benefit than the salmon oil capsules?  If so, do you know if it is yet available in the U.S. (the article you referred to was published in 1996).

Thank you in advance for this information. I appreciate everything you do to further the quest for a cure for Crohn’sand UC.

P.S.  My son is currently a patient at the Univ. of Iowa Hospitals (Center for Digestive Diseases). Do you feel they have an adequate “handle” on IBD? Are you taking new patients?

U of Iowa is well respected.  An important question in getting a handle on the case is to be sure they know your son is on a number of non-prescribed medications.  There is a misconception that many share that natural remedies are not medications.  Consider this:  A drug is a substance which is taken to affect a patient’s metabolism in some desireable way.  These natural products really are being used as medications by many.  The trouble doctors have in dealing with them is that there is in general no safety or efficacy data available to base any recommendation upon.  The drug companies that sell these materials have lobbied congress and have gotten laws passed that have prohibited regulation of themselves.  They also have a fig leaf of a regulation that says as long as they just say the magic words “nutritional supplement”they can market to the public without any regulatory oversight.

There is another misconception that natural substances are safe. There are tragedies in the medical literature of liver failure causing death in several children due to daily administration of certain herbal teas.  The teas were known to be hepatotoxic, but the labelling didnot include this (didn’t have to, it was a nutritional supplement). There are a number of natural substances that are known to be toxic insufficient doses.  Nicotine, caffeine, digitalis, aspirin, strychnine,castor oil, ipecac, poppy juice, to name a few.  (The last exampleis particularly instructive. Poppies are a source of opiates which causedwell documented toxicity to Dorothy, Toto, and the Cowardly Lion. The Tin Man and Scarecrow were spared, due to a difference in metabolism.) There are cases of death due to contaminated tryptophan.  Just because something comes in pill form does not mean it is as safe as people have come to expect from pills from regulated drug companies.

You may be aware that the risk of drug interactions goes up with thenumber of drugs taken.  With your son being on four different additionalmedications than prescribed there is the potential of drug interactions.

So, what are the drugs you are giving your child doing?  I don’tknow.  Indeed, I know that no one can know.  The products describedare all complex.  Aside from the vitamins, their manufacture is notregulated.  Fish oils can be a source of dioxins.  I wonder ifany of the nonprescription drugs your son is on have been through any regularmonitoring of known or likely contaminants.  The medical literaturealso contains articles showing that the unregulated drugs are sometimesmisidentified by the manufacturer.

I try to limit my advice to matters for which there is some sort ofexperience with the substance at hand which can predict how a patient willdo.  The need for the evidence to be predictive is what patients reallywant.  It is expected that a doctor could explain what the expectedeffect would be, what the side effects would be, and the chance of eitherhappening.  For the majority of unregulated drugs, the evidence forthe medicines marketed as nutritional supplements is anecdotal, which doesnot help one make predictions as to how a patient will respond.

All that said, what can I say about your particular questions?  Well, I do not have data on efficacy or side effects of Salmon oil in Crohn’s. Thus, prediction of relative effects is not possible.  (I even donot know if Purepa is whole fish extract or part fish extract.  Asa licensed drug, processing must adhere to Italian good manufacturing practicesand will therefore be consistent lot to lot.)  I also do not knowwhat interactions would develop, if any, with the other medications heis on.  As to Purepa, note that the patients in the study were selectedwith criteria that predicted a high chance of relapse.  The singlestudy thus applies to patients with the same clinical features.  Itis probably generalizable to patients outside Italy, though the fact thatItalians eat more olive oil is one reason that studies in other countrieswould be good.  Whether the drug would be beneficial to patients witha lower risk of relapse is not known.

The simple answer, therefore, is “I do not know.”  The reason forwriting all of the above is to explain the underlying concerns that I asa physician have that causes me to say “I do not know”.  As a fellowprescriber of medications I urge you to consider the risks and benefitsof your recommendations.  Also, I hope that you are keeping recordsof clinical response and medications (including dose and regimen and lot/batchnumber).  These records would be valuable for determining likely candidatemedications relating to clinical response, good or bad.

I hope for the best in your son’s case.

What does one do to get off prednisone?

Often patients are on steroids for some time. What is the protocol for stopping steroids?

Prednisone is a drug often used in IBD. What does one do to get off prednisone?

Usually, prednisone can be tapered rapidly down to 10 mg/day andthen more slowly tapered to none in normal people. In patients withIBD, tapering faster than 10 or 5 mg per month can induce a flare. IBD patients also tend to flare when their dose gets down to 10 to 30mg/day, usually 15 to 20 mg/day. I find it interesting that the doseis very consistent for a given patient, so a patient’s previous taperexperience is quite helpful. When one gets to the wall, tapering at2.5 mg/day each 2 to 4 weeks is usually done, and often the dose hasto go back a step up during the taper.

Steroid tapering is unpleasant, and the symptoms of the taper canfeel just like IBD. Malaise and joint pains are quite common. Thisis worrysome to both doctor and patient. After a few tries attapering and failure but no overt signs of IBD relapse, a decision ismade that it is steroid withdrawal, courage develops and one pushesthrough, usually with success.

All the above is for people not under certain stresses. Theadrenals put out about 35 mg/day of cortisol, which is about the sameas 10 mg/day of prednisone. Under stress, the doses needed arehigher. Someone who has been on prednisone for a time who is tapereddown to 10 mg/day, then gets pneumonia will need supplemementalsteroids until the infection is cleared. Even after being taperedoff steroids, for a year afterwards patients may need supplementalsteroids during times of metabolic stress.

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

Comments about non-injected vitamin B12

B12 is available in nasal form. How does that compare with classically injected B12?

The uselessness of sublingual Vitamin B12?

In the past I criticized the use of sublingual vitamin B12. Now there is nasal B12 available. A recent article in Gastroenterology[1] showed that nasal B12 is effective in treatment of B12 deficiency, using a dose of1.5 mg per day. 

Patients with Crohn’s disease often have involvement of the last part of the small intestine, which is known as the terminal ileum. That part of the intestine is responsible for absorption of vitamin B12. Vitamin B12 is a large molecule that will not cross any part of your body unless it is specifically brought across by a transport system. For B12 this requiresa system that involves a special protein made in the stomach, called intrinsicfactor, and the transport system in the terminal ileum which brings B12 into the body when it is bound with intrinsic factor. 

What is interesting is that there is a second way to absorb B12 that does not depend on the usual route. This pathway was described years ago, but requires high dose of B12, about one mg per day. I suspect that the B12 given nasally is eventually swallowed and absorbed by the intestinal route.

Interesting that now B12 is available in these formulations. While true that one gets away without a shot, the dose is about 300 times what is given orally. I imagine that 350 to 475 mg of vitamin B12 a year adds up in cost, and it may indeed be cheaper to just get a yearly shot of 1 mg of B12. Add to that the cost of testing to see if the oral or nasal B12 is getting in the system, and I wonder about the cost.

Patients with Crohn’s are at risk for B12 deficiency. Blood counts should be done regularly. In the future, as folate is added to the diet, looking for large blood cells as a clue to B12 deficiency will no longer work, so B12 levels will need to be every few years or so to detect the developmentof B12 deficiency in patients.

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

  1. Slot, WB and Merkus, FW and Van Deventer, SJ and Tytgat, GN. Normalization of plasma vitamin B12 concentration by intranasal hydroxocobalamin in vitamin B12-deficient patients. Gastroenterology 1997 Aug; 113(2):430-433.

How do doctors deal with patients who have incurable disease?

Ever wonder if your doc gets frustrated over not being able to cure incurable disease. Do you worry that you are only darkening the door of your physician, sorry to trouble them over something they cannot cure anyway? A reader asked, and I answeredHow do doctors deal with patients who have incurable disease?

A reader asked:

I’m truly curious as to how doctors deal with the frustration ofdealing with people they can’t, despite their best efforts, cure. I’m wellaware that my doctors are doing their best and that there isn’t a cureor quick fix — I wonder if they know I know that (and of course, I dotell them). Nonetheless, sometimes I hate to even darken their doors withyet another complication or flare-up — perhaps because I am so fond ofthem and appreciative of their efforts. I sometimes think we patients –with all our kvetching — would benefit from an understanding of our physicianson this human level. It’s not a topic I’ve ever seen or heard addressed.

Oh, yes, this is a common question of Doctors. Well, I think it is. I actually haven’t canvassed my fellow physicians on this one, but I have had friends ask me. 

Actually it is quite easy. Starting out in medical school, one imaginesthat you will become a docto n sae lives. Then you got on the wards, andthe livess are not that easy to save. After the shock of realizing thatone is unable to cure everything, the young physician learns to do thebest they can. I think ther ismoreto it then just the best that you can.For myself, I have also found a way of looking at the issue that workswell for me. I have decided that my role is to give advice. This has mademe much more comfortable. My ego is no longer dependent on patients takingtheir medicines. Nor does my ego anymore depend on the virulence of someonespnuemocccus. By realizing that I give advice, I am in balance with my abilityto impact the world. When a patient is not able to follow my advice, Ino longer feel frustrated, I look for ways to give better advice. Whenthings do not work as planned, I recognize that information is imperfectand I look for more information in order to give better advice. When Idecide on what initial tests to do, I do not fear not getting every testpossible. I get sufficient tests to allow me to give reasonable adviceunder the circumstances.

Say someone has a terminal disease. I find out what last things theywant to do: such as get to their sons graduation. Then I give advice onhow to best achieve those goals. Sometimes the effort will need to be greatto get a few extra days, but it will be worth it. With Crohn’s, I knowwhat the odds and consequences are of different choices, so I give adviceon how to deal with problems as they occur. As advice depends on goals,it is a natural extension to involve my patients in the decision makingprocess, not to decide what is the correct thing to do, but to help meunderstand what different consequences mean to my patients, so that theadvice I give makes sense in the patient’s contest. So my measure of successis whether the advice caused the best possible outcome given the circumstances.

So the next time you worry you are darkening your docs door, remember that you are not there for a cure, you are there for advice. By having a physician that understands your situation and goals, and by providing feedback on how the disease and treatment are being tolerated, you will be able to get advice to help you deal with the situation at hand.

Best of Luck, 

Stephen Holland, M.D.
Section of Clinical Pharmacology
University of Illinois College of Medicine at Peoria

You want to get Pregnant while on Azathioprine?

Many women with Crohn’s are on azathioprine, an immunosuppressant. What should you do if you want to get pregnant while on azathioprine?

The subject of pregnancy and inflammatory bowel disease has been writtenabout extensively. Treatments are changing, and one worries about the effecton the unborn child. One reader wrote the following:

Thanks for an informative web page. I also subscribe to the IBD list and appreciate your comments. I have looked through some old IBD posts and saw where you said taking Imuran when conceiving a child gave you the willies. I was diagnosed with Crohn’s in 1993. I am now 27 years old and my husband and I want a child. I have been taking Imuran (50 mg a day)since November 1994. My GI has reluctantly agreed to let me try to taperoff Imuran. He feels Imuran is the reason that I was finally able to taper off prednisone after 3 years. I have been on Pentasa since March 1994.My GI feels that I will have a flare up when I discontinue the Imuran andthat would be a greater risk to the baby than the risk of birth defectscaused by continuing to take Imuran. My OB says the Imuran is unsafe duringpregnancy. I also would like to breast feed and Imuran would make thatimpossible. I’ve been told by my GI and OB that Pentasa is safe during pregnancy.

The above situation is a real example of the problems that face onewho is contemplating pregnancy with Crohn’s. The physicians seem to begiving contradictory advice. Actually, each is concerned about the outcomefor the patient, and different factors come into play. 

While no one advocates the use of Azathioprine in pregnancy, the reportsof the outcomes for patients on azathioprine who get pregnant seem to beno worse than the results of patients with untreated Crohn’s. That is tosay, fetal loss is common in active Crohn’s and also when on azathioprine.The incidence of birth defects is not higher when on azathioprine. My interpretationof this is that if azathioprine causes birth defects in a given pregnancy,they are so severe that the fetus will not survive. There was some controversya while back on what the effect of pregnancy on Crohn’s is. I think theliterature pretty much now shows that people respond variably, but thatif Crohn’s is active at the time of conception that things will probablynot go well. 

All that said, most drugs used in treatment of IBD have been found tobe safe during pregnancy. Steroids are known to be safe, as is sulfasalazine.Mesalamine is probably safe during pregnancy. Flagyl is not to be used(though the data I recall are just scattered case reports, and the warningto not use it may not stand up in the future). 

Remember that many people were successfully treated with medicationsbefore azathioprine came into common use for Crohn’s disease. While azathioprinemay be used to get a patient off steroids, the situation generally is notthat steroids were ineffective, but that steroids were needed chronicallyand side effects were a concern. 

My feeling about this is that since pregnancy is self limited in duration,getting off azathioprine at worst will mean 12 to 16 months of steroids.If the Crohn’s can be controlled with other medications, then all the better.In general, I would advise patients on azathioprine to get off the azathioprineand start steroids, a form of mesalamine, or both depending on circumstances.Also, I generally advise Crohn’s patients to avoid anything with sucrosein it, since some studies in the past showed a 50% reduction in complicationsof Crohn’s when that was done. 

The above notwithstanding, there is the possibility that a particularcase of Crohn’s was so bad that even the thought of recurrence is painful.I could imagine someone who had multiple fistulas, obstructions, operationsand wound failure, was starting to get cataracts, and who only got outof a cycle of repeated hospitalizations when put on azathioprine. A casesuch as that might warrant the risk of azathioprine. 

I cannot tell what is the right choice, however. This will depend onhow the risks sound to you and many aspects of your views on life, death,having children, and dealing with birth defects. It is not your responsibilityto make the medical decisions, but the input to your physicians on howyou value the various outcomes will let your doctors, who have a sensefor the relative rates of occurrence of the above outcomes, give betteradvice on how to proceed. 

Best of luck in your efforts!

Stephen Holland, M.D.
Section of Clinical Pharmacology 
University of Illinois College of Medicine at Peoria