Crohn’s Disease
(CD)
Oluchukwu Okonkwo
Florida A&M University
4th Year PharmD. Candidate
Objectives
 Discuss the prevalence and
epidemiology of CD
 Briefly discuss the causes and
pathology of CD
 Define clinical features and diagnosis
of CD
 Review therapies for CD and discuss
the pharmacist role in CD
Prevalence
 ~5 new cases in every 100,000
 ~30 in every 100,000 people live
with CD
 >700,000 physician visits
 100,000 hospitalizations
 119,000 disabilities
Epidemiology
 Late onset
 Both sexes are affected equally
 $ 2 billion annually
 66-75% of patients with CD will
require surgery
Etiology
Four Factors
1. Infectious
2. Environmental
3. Genetic
4. Immunologic
Pathology
 Extent and depth of inflammation of
bowel wall
− Extraintestinal in CD
− Limited to colon in UC
 transmural inflammatory process
 terminal ileum is the most common
site of the disorder
stenosis of the terminal ileum
Clinical features of CD
Diagnosis
 CT san, MRI or X-ray
 Colonoscopy or Capsule endoscopy
 CBC with white cell differential
 Stool culture
Differential diagnosis
 Irritable Bowel Disease
− Ulcerative colitis
− Irritable bowel syndrome
Small bowel obstruction
Malabsorption syndrome
Cancer
− colorectal
− small intestine
Pancreatitis
Goals of therapy
 Resolution of acute inflammatory
processes and complications
 Alleviation of extra-intestinal
manifestations
 Maintenance of remission
Non-Pharmacological
Therapy
 Surgical procedures
− colostomy
 Nutritional considerations
− Enteral supplementation
− Parenteral nutrition (limited)
 Herbals
− Cascara & Senna
− Psyllium
− Peppermint & Chamomile tea
− Lactobacillus or bifidobacterium
Pharmacological Therapy
Antidiarrheals
Peals
• Mild symptom
control: Diarrhea
• Pseudomembranous
colitis CI
• Children with viral
illness at risk of
Reye’s Syndrome
1. Loperamide (Imodium)
2. Bismuth subsalicylate
(Pepto-Bismol)
3. Diphenoxylate +
Atropine (Lomotil)
Side Effects: abdominal
cramping, constipation,
nausea, black tongue/stool,
hearing loss, tinnitus,
sedation, urinary retention,
tachycardia, xerostomia
Antispasmodic
Peals
• Mild symptom
control: Cramping/
GI Spamas
• Several CI: GI
obstruction, sever
ulcerative colitis,
reflux esophagitis,
narrow-angle
glaucoma,
myasthenia gravis
1. Dicyclomine (Bentyl)
Side Effects: constipation,
sedation, urinary retention,
tachycardia, xerostomia,
blurry vision, confusion,
lightheadedness
Steroids
Peals
• Decrease severity of
Acute Attacks
• Not intended for
long-term use
• Lower systemic
exposure with
Budesonide BUT sig
drug-interactions
1. Prednisone
2. Budesonide (Entocort
EC)
Side Effects: increased
appetite/ weight, fluid
retention, emotional
instability, insomnia, GI
upset, increase BP, increase
BG, Cushing’s syndrome,
osteoprosis
Aminosalicylates
Peals
• Maintenance therapy
• Monitor renal
function, CBC, and
symptoms of IBD
• Sulfasalazine can
cause a yellow-orange
coloration of
skin/urine AND impair
folate absorption
1. Mesalamine (Asacol)
2. Sulfasalazine
(Azulfidine)
Side Effects: abdominal
pain, nausea, headache,
flatulence, eructation,
pharyngitis, acute
intolerance syndrome; rash,
anorexie, crystalluria,
oligospermia
Immunosupperssive Agents
Peals
• Maintenance therapy
• Monitor renal
function, CBC, and
LFTs
• Methotrexate is Preg.
Category X
• Leucovorin
Antidote
1. Azathioprine ( Azasan)
2. 6-Mercaptopurine
(Purinethol)
3. Methotrexate
(Rheumatrex)
Side Effects: GI upset, rash,
↑ LFTs, hematological
toxicities,
mucositis/stomatitis, skin
reaction
Monoclonal Antibodies
Peals
• Maintenance therapy
• Monitor vitals, CBC,
LFTs, infection,
HBV screening, HF
• Patients MUST
Tysabri enroll in
TOUCH
• Humira has lower
antibody
developement
1. Infliximab (Remicade)*
2. Certolizumab
(Cimzia)*
3. Adalimumab (Humira)*
4. Natalizumab (Tysabri)*
Side Effects: infusion
reactions- hypotension,
fever, chills, pruritis,
infections
Special Population:
Pregnancy
 Improving nutrition
 folate, calcium, Vit. D, ceasing
alcohol and tobacco use
 Safe Use
− TNF- inhibitors
− Sulfasalazine
 folic acid 1 mg twice daily
− Cyclosporine
− Steroids given systemically
 exception with dexamethasone
 Don NOT use
− Immunosuppressive
− Methotrexate
Pharmacist role
 Provide patient counseling and
education
 Asses therapy for drug interactions
and optimal outcomes
 Patient QOL assessment should be
performed regularly
− Stress management
References
1. Boye B, Lundin KE, Jantschek G, et al. INSPIRE study: Does stress
management improve the course of inflammatory bowel disease and
disease-specific quality of life in distressed patients with ulcerative colitis or
Crohn's disease? A randomized controlled trial. Inflamm Bowel Dis
2011;17(9):1863–1873.
2. Lichtenstein GR, Hanauer SB, Sandborn WJ, The Practice Parameters
Committee of the American College of Gastroenterology. Management of
Crohn's disease in adults. Am J Gastroenterol 2009;104:465–483
3. Buchner AM, Blonski W, Lichtenstein GR. Update on the management of
Crohn's disease. Curr Gastroenterol Rep 2011;3:465–474.
4. Micromedex Healthcare Series. DISEASEDEX® Summary. Crohn’s Disease.
2013. Thomson Healthcare Inc.
5. Hemstreet B.A. (2014). Chapter 21. Inflammatory Bowel Disease. In J.T.
DiPiro, R.L. Talbert, G.C. Yee, G.R. Matzke, B.G. Wells, L.M. Posey (Eds),
Pharmacotherapy: A Pathophysiologic Approach, 9e.
Questions