News

Granulocyte-monocyte apheresis in patients with ulcerative colitis

January 10, 2023

Adacolumn

After having been diagnosed with ulcerative colitis (UC) or Crohn’s disease, the path patients with inflammatory bowel disease (IBD) and their families take is hard. Accepting the news they have received, attending all the consultations with specialists, performing the relevant tests to understand the scale of the disease or the time it takes to adjust and establish the correct treatment, are just some of the obstacles and challenges they must overcome. Indeed, one of the most complex points that the patient has to face is to succeed in receiving appropriate treatment.

Focusing on the case of ulcerative colitis, a condition that causes inflammation in the rectum and the colon, the patient suffers relapses with more or less intense activity flare-ups, which are more or less long-lasting. The current drugs in the healthcare professional’s therapeutic arsenal for treating patients aim to induce remission of these flare-ups and keep IBD inactive to improve the patient’s quality of life. With the best efficacy and safety possible, of course.

Taking into account that some patients do not respond to conventional treatments or cannot use them due to their profile, healthcare professionals have seen granulocyte-monocyte apheresis (GMA) as a therapeutic ally offering proven benefits in patients with ulcerative colitis. This happens because the technique reduces the amount of existing inflammatory cells in the bloodstream without giving the patient anything.

What is granulocyte-monocyte apheresis?

As commented above, GMA is a non-pharmacological treatment whose basis is to pass the patient’s blood via an extracorporeal device to remove from it those pathogenic inflammatory components that determine or perpetuate the disease, thereby contributing to their treatment.

One of the granulocyte-monocyte apheresis systems sold in Europe is a system comprising a column or filter with cellulose acetate beads that enable the selective adsorption of 65% of granulocytes, 55% of monocytes/macrophages and 2% of lymphocytes, removing them from the bloodstream.

The procedure involves taking blood from the patient’s cubital vein, which flows through the circuit and the adsorption column where it is purified, and is re-infused via the contralateral cubital vein (fig. 1, we include the image of the process).

The procedure is performed in haemodialysis or apheresis units, although it can be performed in treatment units at day clinics after suitable training. The regimen for applying the technique (frequency and number of sessions) ranges from 5 to 10 sessions (1 or 2 a week) of 60 minutes or more, although actual clinical practice in the majority of hospitals involve an induction of 10 sessions (2 sessions/week for the first 3 weeks to accelerate response and then 1 weekly session until completing 10) and for a longer duration (normally 90 minutes), as this regimen has been observed to be safe and well-tolerated, obtaining the best clinical results.

Nevertheless, the only practical limitation to performing it is poor accessibility for inserting peripheral lines, which may require inserting a central line.

GMA’s mechanism of action is currently still not completely known. However, it is known that peripheral blood granulocytes and monocytes/macrophages are elevated and activated in many autoimmune diseases, whose numbers are linked to the activity and severity of the disease, and which play a key role in the disease immunopathogenesis while producing larger amounts of pro-inflammatory cytokines that are responsible for the tissue damage.

It is believed that GMA’s main adsorption mechanism is linked to the activation of the complement system’s cascade and the induction of granulocyte adhesion to the column.

Leukocytes that express Fc gamma receptor (FcγR) and complement receptors (Mac-1, CD11B/CD18) adhere to the cellulose acetate beads through activation of the complement. Thus, the decreased reservoir of activated granulocytes in the circulatory system is compensated by the mobilisation of young inactive granulocytes (CD10-) from the bone marrow to the bloodstream, without the ability to migrate to the inflammatory focal point.

Likewise, a functional change occurs in the activated monocytes, which express CD14+CD16 markers, which altogether leads to a reduction in the production of pro-inflammatory cytokines and an increase in circulating anti-inflammatory mediators; in summary,  a phenomenon of immunomodulation and, accordingly, a reduction in inflammatory infiltrate and tissue damage. The direct consequence of removing leukocytes from the circulatory system is the mobilisation of young inactive leukocytes from the bone marrow, which cannot migrate to the inflammatory focal point. What is more, passing the blood through the column, in addition to decreasing the total number of inflammatory cells in the blood, also causes changes onto the surface of those that return to the body leading to a series of immunological changes that enhance the activation of previously inhibited anti-inflammatory mechanisms, initiating the resolution of inflammation. By doing so, in addition to producing immunomodulation (a change in the immune system), it reduces inflammation and tissue (cell) damage in the intestinal mucosa.

GMA is indicated for use in which patients?

There is currently a very broad therapeutic arsenal for treating IBD even though for a number of patients, these medications are ineffective or have adverse events2. Other therapeutic options are therefore needed to monitor the progression of the disease and avoid surgical procedures.

In certain scenarios, GMA is an alternative for treating this disease. This technique can be applied to different situations, including patients that do not respond well to conventional pharmacological treatments, or have a corticosteroid-dependent course, preventing relapse and in whom immunosuppressive or biological treatment is considered3,4.

Despite seeking the best treatment for each case, there is a high percentage of patients with ulcerative colitis that do not respond to conventional treatments,either those based on corticosteroids or immunomodulators (IMM thiopurines) (Ardizzone et al, 2006) or anti-TNF therapy. Until a few years ago, when a healthcare professional was in this situation where drugs failed to improve the patient’s condition, the most used option for treating them and improving their quality of life was surgery.

However, in recent decades, other treatment alternatives for patients with ulcerative colitis have emerged, like GMA, which are safer and can be applied to the following patients1:

  • Adult patients with corticosteroid-dependent ulcerative colitis after failure, intolerance or elevated risk of immunomodulatory treatments and/or biologics2.
  • Elderly patients with comorbidities.
  • Pregnant patients.
  • Paediatric patients with ulcerative colitis.

The contraindications are:

  • Heparin allergy and heparin-induced thrombocytopenia
  • Granulocyte levels below 2000/ML
  • Severe anaemia (Hb < 8 g/dL)
  • Severe coagulopathy
  • Active infection
  • Severe heart or kidney disease
  • Precautions:
  • Care in situations of hypercoagulability (fibrinogen > 700 mg.mL) or dehydration (diarrhoea or recent fevers). These factors need to be corrected beforehand.

GMA, significance of efficacy and safety in UC treatment

If there are two features that define GMA, they are its safety and efficacy. As stated by Prodiggest Project3, this therapeutic option has been the subject of studies andmeta-analysis that describe it as an effective and safe alternative for patients.

On the one hand, GMA is described as being very safe for patients with ulcerative colitis because the adverse events of conventional treatments disappear. In this case, the majority of side effects are mild and temporary allowing the patient to continue with the treatment. Notably among them are headaches, chills, low-grade fever, dizziness, fatigue, myalgia, palpitations, hypotension or redness. In many case, the adverse events are linked more to the apheresis technique than to GMA treatment itself (issues with the lines etc), hence the importance of being performed by skilled professionals.

On the other hand, in addition to its efficacy in paediatric, pregnant or elderly patients, or corticosteroid-dependent and corticosteroid-refractory patients, there are other scenarios where GMA is effective. For example, it has proven that it can be a first-line treatment in distal ulcerative colitis with mild-moderate activity with a remission induction rate of 70% (Yamamoto et al 2004) and up to 80% in patients whose disease is less developed, steroid-naive (Takemoto et al 2007), as stated in Prodiggest Project.

Furthermore, it is an option that can prevent relapse in certain patients at high risk of having recurrent and difficult to control flare-ups. Accordingly, a mean duration of clinical remission obtained with GMA of 10 months can be established in patients with ulcerative colitis (Ljung et al 2007), and can even be much longer than a year the earlier the disease or the less treatment the patient has received prior to GMA (corticoids, thiopurines, biologics, etc.).

  1. https://www.aegastro.es/publicaciones/publicaciones-aeg/protocolos-asistenciasles-prodiggest/uso-racional-de-la-granulocitomonoaferesis-en-la-enfermedad-inflamatoria-intestinal
  2. Adacolumn® – Adacyte
  3. https://www.aegastro.es/publicaciones/publicaciones-aeg/protocolos-asistenciasles-prodiggest/uso-racional-de-la-granulocitomonoaferesis-en-la-enfermedad-inflamatoria-intestinal
  4. Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel JF, AllezM, et al. Second European evidence-based consensus on thediagnosis and management of ulcerative colitis part 2: Currentmanagement. J Crohns Colitis. 2012;6:991—1030.
  5. Dignass A, Akbar A, Hart A, et al. Safety and efficacy of granulocyte/monocyte apheresis in steroid-dependent active ulcerative colitis with insufficient response or intolerance to immunosuppressants and/or biologics [the ART trial]: 12-week interim results. J Crohns Colitis. 2016;10:812–820.
  6. Dittrich K, Richter M, Rascher W, et al. Leukocytapheresis in a girl with severe ulcerative colitis refractory to corticosteroids, infliximab, and cyclosporine A. Inflamm Bowel Dis. 2008;14:1466–1467.

News

Inflammatory bowel disease in elderly patients

December 13, 2022

Patient

IBD elderly patients

Monitoring nutrition and staying physically active are the two key points for leading a healthy lifestyle. Although this fact is important at any age, it is even more so if we wish to reach old age in good health conditions. The onset of conditions, such as inflammatory bowel disease (IBD), is possible during this phase, especially from the age of 60. Out of the elderly patients diagnosed with ulcerative colitis1 or Crohn’s disease for the first time, 65% are aged between 60 and 69 years; 25% between 70 and 79 years; and 10% over the age of 80.2

Inflammatory bowel diseases are often accompanied by another type of known secondary condition, such as extraintestinal manifestations (EIM), which affects the skin, eyes or joints, even though they are less common in elderly patients. There are also surgical procedures, postoperative recurrence and the onset of more aggressive or severe forms of IBD.

Malnutrition, anaemia and osteoporosis in elderly patients with IBD

Having a varied, complete, balanced diet3 in elderly patients, especially those with IBD, is fundamental but not always feasible. Issues can arise whilst chewing and swallowing due to tooth loss and decreased salivation, or can worsen the digestive process as a consequence of the reduced amount and quality of digestive secretions that, accompanied by intestinal mucosal atrophy, results in worse absorption and reduced benefit from some nutrients, mainly proteins, vitamins and minerals.

The issue of malnutrition thereforearises due to a declining diet, which causes anaemia4. Although this is not the only reason. Elderly patients with IBD can also have anaemia and malnutrition due to blood loss via the gastrointestinal tract. Hence the need for elderly patients with ulcerative colitis and Crohn’s disease to ensure they are ingesting iron-rich foods daily, notably fish, meat and eggs.

Malnutrition in elderly patients with IBD is also one of the causes for the onset of osteoporosis. Calcium, phosphorus, magnesium and vitamin D deficiencies, among other components required for bone formation, influence the loss of bone mineral density and bone weakening or fragility, thereby increasing the risk of fractures.

To prevent osteoporosis in patients over the age of 60, it is recommended to stop smoking, take the right amount of calcium and vitamin D, and exercise regularly. In fact, moderate physical activity increases bone mass and strengthens muscle. Dancing, walking, running, performing aerobic exercise, climbing stairs or lifting weights are some of the activities that the population at risk of osteoporosis should perform.

Treatment of elderly patients with IBD

The healthcare professionals’ criteria for selecting a treatment and establishing the regimen to be followed by elderly patients with ulcerative colitis or Crohn’s disease are often similar to those taken into account when determining medication for any other population group. Even the efficacy and results that can be expected from the drugs are also similar.

Nevertheless, when patients over the age of 60 have comorbidities, it is possible that the impact of adverse drug reactions are greater. In these cases, consultant specialists count on their therapeutic arsenal with treatment options, such as granulocyte-monocyte apheresis (GMA)5. Thanks to this non-pharmacological treatment, activated leukocytes that are responsible for intestinal inflammation are safely removed from the patient’s blood. In this way, safety is increased and risks to fragile patients, such as elderly patients, are reduced to a minimum.

  1. What is ulcerative colitis? – Adacyte
  2. https://educainflamatoria.com/pacientes-eii-edad-avanzada/
  3. Five keys to a proper diet if you have ulcerative colitis – Adacyte
  4. Relationship between anemia and Inflammatory Bowel Disease – Adacyte
  5. Adacolumn® – Adacyte

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Surgery for ulcerative colitis: before, during and after

November 8, 2022

Patient

cirugia colitis ulcerosa

Physicians have an extensive therapeutic arsenal for treating patients with ulcerative colitis. Available drugs keep the disease inactive or in remission in most cases. Despite this between 25% and 40% of patients with ulcerative colitis will need surgical treatment at some point in their illness1.

Unlike Crohn’s Disease2, surgery in ulcerative colitis is curative. The fact is that, by affecting the rectum and the colon, its removal implies the total healing of the patient.

In particular, surgery is indicated3 when the pharmacological treatment has not controlled the symptoms of ulcerative colitis; when complications such as stenosis (narrowing or reduction of the internal diameter of the intestine), perforation, severe bleeding, abscesses or fistulization occur; when premalignant or carcinogenic lesions develop;  or when perianal disease occurs and drainage surgery is necessary, derivative colostomies to isolate fistulas from passing stool or radical protections in advanced cases.

Preparation of the patient before surgery

The surgeon and the gastroenterologist study the progress of ulcerative colitis in the patient to determine the extent and severity of the symptoms. Afterwards, they inform him about the technique best suited to his situation and the benefits, complications and risks associated with it4.

Before surgery5, the patient will undergo a preoperative study consisting of: blood and urine analysis, chest x-ray and electrocardiogram. In addition, it is very important for the patient to be in good general condition and to discontinue the treatment he is taking (corticosteroids, immunosuppressants or biologic therapy, granulocyte apheresis…), if any.

Two days before the intervention, the patient should follow a liquid diet so, with the help of an intestinal preparation, the intestine is emptied of waste or traces of feces.

Surgical interventions in the treatment of ulcerative colitis

The gastroenterologist and surgeon may choose from a variety of surgical techniques to treat ulcerative colitis6. Among the most common ones stand out: the total proctocolectomy with ileostomy or with ileoanal reservoir. It is also very common to perform a total colectomy with ileorectal anastomosis, and subtotal colectomy with ileostomy and rectosgmoid mucous fistula.

When a total proctocolectomy is performed, the entire rectum and colon are resected. If it is decided to perform a total proctocolectomy with ileostomy, an opening or hole is made that connects the ileum to the outside (ileostomy) to remove the intestinal waste in a bag (ostomy).

In the event that medical professionals choose to perform a restorative proctocolectomy or ileoanal reservoir, an internal reservoir or pouch is created with part of the small intestine (ileum) that will be attached to the anus and function as a new rectum.

The technique known as total colectomy with ileorectal anastomosis consists in resecting the entire colon and joining (anastomosis) the ileum with the rectum. For its part, in the subtotal colectomy with ileostomy and rectosgmoid mucous fistula, only the affected areas of the colon are resected and an ileostomy is performed. If the sigma (the end of the colon) is not affected, it is left intact and communicates with the outside through the anus or through a mucous fistula performed on the abdominal wall for the secretions to come out.

What happens after surgery in ulcerative colitis?

After the surgery in ulcerative colitis, the patient’s recovery comes.  Initially, he will not be able to ingest any type of food. He will only receive nutrients through parenteral nutrition, intravenously. Once the intestinal movement is restored, he can gradually begin to swallow liquids and subsequently solids.

Furthermore, it is common for the patient to evacuate traces of blood, mucus and/or feces through the rectum, sometimes, without being able to help it. That is called rectal incontinence. If the rectum is intact, he will not experience any pain during evacuation. The frequency of these secretions will decrease over time.

In the case of an ostomy, the patient should begin to get used to his new situation as soon as possible. His intestinal function will be altered, his body image will change and he will have a stoma. During his hospital stay, healthcare professionals will help the patient and his family adapt, offering them all the advice and information they need.

However, given the changes in the patient’s quality of life and the complications usually associated after this surgery (cross with new article commenting on this topic), it is always reserved as the last alternative and when the rest of available treatments have not been effective in the control of ulcerative colitis.

  1. https://www.elsevier.es/es-revista-cirugia-espanola-36-articulo-estado-actual-del-tratamiento-quirurgico-S0009739X12003119
  2. Ulcerative colitis and Crohn similarities – Adacyte
  3. https://www.elsevier.es/es-revista-cirugia-espanola-36-articulo-estado-actual-del-tratamiento-quirurgico-S0009739X12003119
  4. https://www.educainflamatoria.com/que-preparacion-previa-tiene-una-cirugia-de-eii
  5. https://www.elsevier.es/es-revista-enfermedad-inflamatoria-intestinal-al-dia-220-articulo-manejo-perioperatorio-enfermedad-inflamatoria-intestinal-S1696780115000767
  6. What is ulcerative colitis? – Adacyte

News

Biologic treatment for Ulcerative Colitis: a therapeutic revolution

October 13, 2022

Patologies

The last 30 years have been a revolution in the treatment of Inflammatory Bowel Disease (IBD). Healthcare professionals have incorporated into their therapeutic arsenal new molecules that have been shown to be highly effective in Crohn’s Disease and Ulcerative Colitis. In addition, these molecules have made it possible to expand the therapeutic options available to the patient and to move towards Personalized Medicine. We are talking about monoclonal antibodies.

These new drugs are based on different mechanisms of action to which we are accustomed. This is why they will allow, in the very near future, to manage the disease in a much more varied way. Experts predict that the greatest revolution in this field is yet to come. For the time being, they are getting an effective treatment for patients suffering from a moderate to severe outbreak and who have an unfavorable response to conventional treatments or are intolerant and/or have contraindications to such treatments.

What are the biological treatments for Ulcerative Colitis?

Monoclonal antibodies are a type of protein that binds to a cytokine (another type of protein) in the organism called Tumor Necrosis Factor alpha (TNF-alfa). Thus, biological treatment can block TNF activity. This cytokine is one of the molecules responsible for the inflammatory process when an outbreak occurs1 in patients with IBD such as Ulcerative Colitis.

We therefore refer to complex compounds synthesized from an organism or a living cell that are genetically modified with technology and genetic engineering, in other words, by means of an effective and precise biotechnology that allows the manipulation of those cells or microorganisms.

So it can be said that the biologic treatment of Ulcerative Colitis improves patients’ quality of life. That is, unlike other existing medicines, these new biologic drugs allow the disease to be kept in remission for longer periods. In this way, the patient can carry out his daily activities normally without presenting any symptoms.

When and how is administered a biologic drug?

Biologic drugs are indicated for both induction and remission of Ulcerative Colitis. Before recommending administration, the health care professional will focus on the patient’s vaccination status and his immunization status against some infections.

In addition, he will rule out a latent tuberculosis infection. If the patient were in this situation, the bacteria responsible for tuberculosis would be alive in his organism but inactive. Therefore, he would have no symptoms until the virus was activated. In order to rule out this possibility tests such as a chest x-ray, a blood test and a tuberculin test (mantoux) will be performed.

Afterwards, the physician will evaluate which biologic drug to administer the patient from the entire arsenal available. Then, the dose will be stablished and the most appropriate time to start the biologic treatment of Ulcerative Colitis with biologic drugs will be evaluated.

Two forms of administration may be used2 depending on the drug selected:

  • Intravenous. The drug is administered at the hospital using a venous line. Administration will be slow to avoid a reaction to the medication. This is how infliximab, its biologic and vedolizumab are administered.
  • Subcutaneous. The drug can be administered at home by the patient himself as if it were an insulin injection. Adalimumab and golimumab are administered using this method.

In the case of ustekinumab, the first dose is administered intravenously. Subsequent doses are administered subcutaneously.

Diversity of biologic treatments for Ulcerative Colitis

The approval of infliximab marked a turning point in the treatment of patients with Inflammatory Bowel Disease in general and for those with Ulcerative Colitis in particular. Because it was the first formulation of this family of medicines that came into the hands of the doctor. But it has not been the only biological treatment approved.

There are other active substances belonging to the group of Tumor Necrosis Factor antibodies inhibitors or TNF inhibitor drugs. This is the case of adalimumab and golimumab, as well as the biosimilars of infliximab and adalimumab.

For its part, vedolizumab is an integrin receptor antagonist drug. The objective of this active substance is to decrease the entry of inflammatory cells into the intestine. And it does that by blocking the integrins, membrane receptors that allow the passage of white blood cells and lymphocytes into the intestine.

One of the latest biologic drugs approved has been ustekinumab. In this case, it focuses on blocking the action of interleukins 12 and 23. These proteins are involved in the regulation of the inflammatory response. When they are elevated, activation and a lymphocyte proliferation occurs, which in turn provokes an inflammatory response of the organism.

Side effects of biologic treatment in Ulcerative Colitis

Usually, the side effects of biologic drugs are mild. It is common for the patients to feel tired, to experience some skin reactions, nausea, vomiting, joint or muscle pain, and fever3.

When the biologic treatment is performed by intravenous administration with infliximab, adalimumab or golimumab, the patient may report some reaction. For example, shortness of breath, hives, redness, itching and swelling of the lips and throat, or headache. If this were to happen, the infusion would be stopped in order to resume it at a slower rate. In the following administrations, the patient would be premedicated with corticosteroids.

For their part, patients treated with adalimumab or golimumab may have a skin reaction at the subcutaneous injection site.

In general, all biologic drugs can increase the chances of infection, especially respiratory infections. Therefore, health professionals recommend keeping all vaccines up to date. And, if you have any symptoms of infection such as fever or cough, it is advisable to tell your doctor.

  1. https://educainflamatoria.com/tratamiento/opciones-terapeuticas-en-la-eii/farmacos-especificos/
  2. https://scielo.isciii.es/pdf/diges/v107n6/infopaciente.pdf
  3. https://geteccu.org/pacientes/efectos-adversos-de-farmacos-en-eii

News

WORLD PATIENT SAFETY DAY

September 16, 2022

Patient

World Patient Safety Day was established for the first time on September 17, 2019 by the World Health Assembly1. This celebration aims to raise further awareness and participation of society, expand knowledge worldwide and encourage solidarity and action to promote patient safety globally.

In line with this approach, a specific theme is highlighted each year to be emphasised in order to reduce avoidable harm to patients and in pursuit of international health coverage. In addition, the Global Patient Safety Action Plan 2021-20302 has been developed with the mission to Drive policies, strategies and actions, based on science, patient experience and partnerships, to eliminate sources of avoidable risk and harm to patients and healthcare workers.

Past World Patient Safety Day objectives

  • 2019: to raise awareness of the importance of patient safety and to encourage citizens to demonstrate their commitment to this cause under the slogan “Speak out for patient safety”3.
  • 2020: again affected by the pandemic context due to COVID-19, the campaign focused on the issue of healthcare workers’ safety as a basic pillar to ensure patient safety; as stated in “Healthcare Workers’ Safety: A Priority for Patient Safety”4.
  • 2021: emphasis was placed on the significant burden of harm caused to women and newborns who are provided with maternal and child care that is not without risk, especially at the time of delivery when most of the harm is caused. This is particularly important given the disruption to health services caused by the COVID-19 pandemic, which has exacerbated this problem. “Safe Maternal and Neonatal Care”5.

World Patient Safety Day objectives of 2022

For 2022, the theme of the campaign is medication safety under the slogan “Medication without harm”, bearing in mind that everyone in their lifetime will take medication to treat or prevent a health problem. However, sometimes medicines can cause serious harm if they are not stored properly, if they are prescribed or taken incorrectly, or if they are not sufficiently monitored.

The following are the objectives6 that make up this year’s campaign established by the WHO (World Health Organisation):

  • RAISE global awareness of the high burden of medication-related harm due to medication errors and unsafe practices, and ADVOCATE for urgent action to improve medication safety.
  • INVOLVE key stakeholders and partners in efforts to prevent medication errors and reduce related harms.
  • EMPOWER patients and families to actively participate in the safe use of medicines.
  • EXPAND the implementation of the Global Patient Safety Challenge: Medication without harm.

World Patient Safety Day campaign video: September 17, 2022.

  1. https://www.who.int/es/about/governance/world-health-assembly
  2. https://www.who.int/publications/i/item/9789240032705
  3. https://www.who.int/es/campaigns/world-patient-safety-day/2019
  4. https://www.who.int/es/campaigns/world-patient-safety-day/2020
  5. https://www.who.int/es/campaigns/world-patient-safety-day/2021
  6. https://cdn.who.int/media/docs/default-source/campaigns-and-initiatives/patient-safety/announcing-world-patient-safety-day-2022-es.pdf?sfvrsn=c5e32a09_34

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Relationship between anemia and Inflammatory Bowel Disease

September 14, 2022

Patologies

One of the most prevalent complications among patients with Inflammatory Bowel Disease (IBD) is anemia. Although data vary depending on the studies, it is estimated that between 30% and 50% of these patients suffer from it. This complication manifests itself in the form of chronic fatigue, a symptom that has a significant impact on the quality of life of these patients. In fact, it can weaken the patient as much or more than abdominal pain or diarrhea. In addition, anemia can lead to increased morbidity for the patient, with an increase in the number of transfusions, hospital admissions and the average length of hospital stay1.

Avoiding the consequences of anemia in Inflammatory Bowel Disease is one of the main objectives of the gastroenterologist. In his quest to improve the quality of life of these patients, he focuses on correctly identifying patients with anemia and establishing the most appropriate treatment. In fact, he considers anemia as an important factor in the detection, evolution and treatment of pathologies such as ulcerative colitis2. Some professionals even confer it its own entity.

What is anemia?

Anemia is the decrease in the amount of red blood cells or hemoglobin in the blood. As a result, not enough oxygen is delivered from the lungs to the rest of the body’s tissues and, therefore, the cells do not function properly. In fact, according to the World Health Organization (WHO) anemia is achieved when hemoglobin in the blood is less than 13 g/dL in men and 12 g/dL in women. If the values reach 10 g/dL, it is considered a severe anemia.

In short, anemia arises when more red blood cells are destroyed than the amount the organism creates. Some of the symptoms that may alert the patient to this extraintestinal manifestation are: headache, fatigue, tachycardia, irritability, fragility of hair and nails, nausea, vertigo, tinnitus (buzzing in the ears), dyspnea or decreased cognitive capacity, among others. If you have several of these symptoms, you need to see a doctor for a complete blood count and rule out or confirm anemia.

Causes of anemia in patients with IBD

In a patient with Inflammatory Bowel Disease, several factors or mechanisms that triggeranemia usually coexist. Despite its multifactorial nature, two main causes can be distinguished:

  • First, iron loss: It is known as iron-deficiency anemia and is the main cause of this complication. Its origin is usually due to a hemorrhage through intestinal lesions that passes unnoticed. When you lose blood, you also lose iron and hemoglobin.
  • Second, chronic inflammatory disorders may also be responsible for its appearance. In this case, it is known as anemia of inflammation or of chronic disease. The cytokines or pro-inflammatory cytokines, proteins that are characteristic of IBD outbreaks, cause a failure in the functioning of the bone marrow and less hemoglobin is produced. It often coexists with iron-deficiency anemia.

Other causes of anemia in patients with IBD are: deficiency of vitamins such as  folic acid and vitamin B12;  the action of some medicines such as aminosalicylates or thiopurine derivatives; and hemolytic anemia, more present in patients with ulcerative colitis3.

Knowing the cause in order to establish the best treatment for the anemia in Inflammatory Bowel Disease

The lack or loss of iron in patients with Inflammatory Bowel Disease, however mild, should not be considered an insignificant indicator. Nothing could be further from the truth. It is a symptom of some maladjustment in the treatment of ulcerative colitis or Crohn’s disease.

For example, if an evaluation of the patient shows that the IBD is active, the medication will need to be adjusted to control the outbreaks and, in turn, reverse the anemia.

If the patient suffers from iron-deficiency anemia, the inflammation caused by IBD should first be monitored.  It may even be necessary to modify their treatment. And to treat anemia it is possible to use oral iron supplements, intravenously administered iron or, occasionally, it will be necessary to supplement with folic acid or vitamin B12. An iron rich diet is advisable as a supplement and also to prevent this type of anemia.

  1. http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082008000500007
  2. Goodnough LT, Nissenson AR. Anemia and its clinical consequences in patients with chronic diseases. Am J Med 2004; 116 (Supl. 7A): 1S-2S
  3. What is ulcerative colitis? – Adacyte

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Is ulcerative colitis a cause of disability?

August 24, 2022

Patologies

Ulcerative colitis is a chronic disease that, well controlled, allows the patient to have a good quality of life. Therefore, having a diagnosed inflammatory bowel disease does not imply a direct recognition of disability. However, there are cases in which the patient cannot develop a normal academic, working or social life because his illness is permanently or intermittently active. This is when we talk about disability due to ulcerative colitis.

Disability is recognized as an objective means of quantifying the impact a disease has on everyday life. It is defined by the WHO (World Health Organization) as “any restriction or lack of capacity to perform an activity in a manner considered normal”.

Types of disability according to the severity of ulcerative colitis

Disability can be classified as transitory or temporary, or permanent and irreversible. Temporary disability refers to a transitory disability that occurs when the patient suffers an outbreak. In other words, we talk about temporary disability when a patient suffers a serious outbreak1 because his disability lasts until the symptoms subside.

On the other hand, permanent disability occurs when the negative impact on the quality of life is continued over time. Cases in which the patient does not suffer irreversible injuries also acquire this entity. This would also be the case for patients who do have post-surgery sequelae or other complications where the changes are irreversible.

How to measure the influence of disability on the patient’s quality of life?

The patient’s perception of the impact of ulcerative colitis on his quality of life is quantifiable. It is measured through Health-Related Quality of Life (HRQOL). This instrument makes available to the doctor instructions for completing the HRQOL2 questionnaire, a series of items (questions) and response options. These items are usually grouped into dimensions that measure various aspects of health, such as physical, mental and social function.

The completion of the test by the patient makes it possible to evaluate the signs and symptoms of the pathology. It also assesses the limitation or alteration of the patient’s psychological well-being, physical capacity and social activities caused by ulcerative colitis. The patient’s responses are scored to get an overview of his condition or quality of life. Thanks to them, healthcare professionals can improve the well-being of patients with ulcerative colitis3.

Is it possible to prevent disability due to ulcerative colitis?

Given the possibility of developing a disability due to ulcerative colitis, either permanent or temporary, the best prevention is a correct control and follow-up of the disease. Hence the importance of attending established medical visits, following the guidelines indicated in the consultation and maintaining the therapeutic adherence to the treatment prescribed by the doctor When the ulcerative colitis is controlled, the inflammation of the intestinal mucosa disappears; that is, the disease is in remission4. With it, in most cases, the disability also disappears. In fact, in a recent study where patients with ulcerative colitis were treated with a TNF inhibitor antibody and fully responded to the treatment were at a lower risk of developing a disability than those with no clinical response5.

The psychological aspect and the feeling of having emotional support is also essential to help the patient reduce the likelihood of suffering a disability due to ulcerative colitis. Hence, in addition to the patient’s environment, patient associations, such as those of the ACCU Confederation in Spain6, have a decisive role when the patient has to face diagnosis, treatments or, even, to maintain an adequate therapeutic adherence.

In these groups, patients share their experiences with others who are in the same situation or who have already overcome it. Information is also provided on the illness and the care services available to them and they even carry out activities with patients and their relatives.

  1. How to act in case of an outbreak of ulcerative colitis? – Adacyte
  2. https://telecumple.educainflamatoria.com/calidad
  3. What is ulcerative colitis? – Adacyte
  4. Remission of inflammatory diseases – Adacyte
  5. https://www.educainflamatoria.com/introduccion
  6. https://accuesp.com/

News

Causes of ulcerative colitis: What factors trigger the disease?

August 8, 2022

Patologies

When a person is diagnosed with a chronic disease such as ulcerative colitis, they often feel vulnerable, confused, and worried. These feelings and concerns are not just about their own health or their future. It often raises serious concerns about the potential impact of this disease on their offspring. That is why, in the process of learning to live with the disease, patients often need to know the causes of the disease.

In the case of ulcerative colitis, science does not yet have a clear answer. The causes of ulcerative colitis are not known. That is, the specific cause of the inadequate inflammatory response of the immune system in the intestinal mucosa is unknown. However, the researchers are determined to provide an answer to this question. Several studies suggest that the appearance of ulcerative colitis1 may be the result of a complex interaction between various genetic and environmental factors.

Is it genetic predisposition? The causes of ulcerative colitis pointed out by science

Under normal conditions, the intestinal immune system is exposed to many potentially harmful substances and commensal bacteria that are part of our intestinal flora. The immune system is responsible for maintaining a stable balance between intestinal tolerance responses to commensal bacteria and inflammatory responses to pathogens.

However, sometimes there are failures in these responses. Inappropriate and exaggerated responses to bacteria whose presence should be tolerated are triggered. This marks the onset of the disease. Therefore, science considers that ulcerative colitis may be the result of a rupture of the balance between the immunity of the intestinal mucosa and the commensal intestinal flora.

The origin of these failures in the responses of the intestinal immune system is not entirely known, but it is believed to be due to genetic alterations. These can be transmitted to the descendants of patients with UC. However, UC is not considered a hereditary disease in the strict sense. Between 8 and 14% of patients with Ulcerative Colitis have a family history of inflammatory bowel disease. But its manifestation is also influenced by external factors.
Other studies have focused on environmental factors, such as tobacco.

Risk factors that favor the appearance of ulcerative colitis

According to the latest studies, the incidence of ulcerative colitis is between 7 and 10 cases per 100,000 inhabitants2. In fact, it is more prevalent in developed countries with an industrialized lifestyle. Moreover, a study published by the American Journal of Gastroenterology in 20193 shows that people, especially children, who have lived in rural areas have a lower risk of suffering any IBD.

On the other hand, age is a risk factor that influences the appearance of this inflammatory disease. Although the pathology can appear at any age, there is a higher prevalence of ulcerative colitis in the population between 15 and 30 years old. Besides, an increasing number of cases are being diagnosed among children between the ages of 7 and 12. What is the reason? It is probably due to lower exposure to infections during childhood4 and as a consequence the immune system of the intestinal mucosa has poor maturation.

Race or ethnic origin is another risk factor that favors the appearance of ulcerative colitis: white people, especially those with Jewish ancestry of European origin, are more likely to suffer from ulcerative colitis: 5 times more than any other ethnic group.

Diet, NSAIDs and tobacco, do they influence the onset of the disease?

Until a few years ago it was believed that the diet a patient had led during his life could be the cause of the development of an Inflammatory Bowel Disease. But no scientific evidence of it has been found. However, diet can help reduce symptoms and their intensity when the patient has been diagnosed and has a relapse.

The use of drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) is not associated with the onset of ulcerative colitis or with relapse, although some patients have experienced relapses after using them. Therefore, it is essential to be cautious with taking these medicines. It is always necessary to consult with a medical professional.

For its part, tobacco is directly linked to the development of IBD. In fact some studies claim that tobacco is a protective factor against ulcerative colitis5. So much so, that the evolution of the disease in smokers with ulcerative colitis is more moderate compared to that of non-smokers. Even in those who stop smoking, the activity of ulcerative colitis increases. It should not be forgotten, however, that tobacco causes other types of disease, so its use is really not recommended.

  1. https://www.educainflamatoria.com/cual-es-la-causa-de-la-enfermedad
  2. https://www.mscbs.gob.es/biblioPublic/publicaciones/recursos_propios/resp/revista_cdrom/VOL93/ORIGINALES/RS93C_201903013.pdf
  3. https://journals.lww.com/ajg/Abstract/2017/09000/Rural_and_Urban_Residence_During_Early_Life_is.16.aspx
  4. https://www.educainflamatoria.com/que-factores-pueden-influir-en-el-curso-clinico-de-la-enfermedad
  5. https://www.siicsalud.com/dato/resiic.php/87568

News

Aspects to be taken into account when travelling with ulcerative colitis

July 28, 2022

Patient

Suffering from an inflammatory bowel disease like ulcerative colitis1 does not need to an obstacle to travelling. Some patients may perhaps think that doing this type of travelling carries more risks than needed, but nothing could be further from the truth. Good planning performed with the help of the medical professionals in charge of the patient is the best option for travelling peacefully.

The best time for taking a trip, whether for business or leisure, is when they are in remission. Hence the need to find a treatment that has a longer relapse-free period and where applying a systemic maintenance therapy is no longer needed. Studies2 were performed on leukocyte apheresis3 a few years ago that showed the efficacy of this method, providing an average duration of clinical remission of around 10 months (Ljung et al 2007)4.

Taking this into account, and even though the remission rates and duration differ depending on each patient profile, selective granulocytoapheresis (GMA) has been shown to be an effective tool for inducing clinical remission in patients with ulcerative colitis. For that reason, it is a part of the healthcare professional’s therapeutic arsenal for improving the quality of life of patients with ulcerative colitis.

What must be taken into account with respect to drugs for treating ulcerative colitis?

Even though the period of clinical remission has been increased thanks to leukocyte apheresis treatment, the patient sometimes needs to go travelling when they are suffering a flare-up, or a relapse may even start during the trip itself.

In such cases, patients that are going to travel need to take a few precautions regarding the drugs they are using to treat their disease. For example, taking extra drugs is recommended in case of unforeseen circumstances, keeping them in the original packaging to make them easier to identify, and it is recommended to take 2-3 days’ worth of medicine in cabin luggage if travelling by air.

On the other hand, when biologics have to be taken, these should be carried in a cooler bag with refrigerants so that the cold chain remains unbroken.

It is also advisable to take anti-diarrhoeal and antispasmodic drugs, oral rehydration solution (ORS), analgesics and even antibiotics for cases where the traveller has diarrhoea or fever with bloody stools. If no ORS is available, a substitute mixture of 1 litre of bottled water, 6 tablespoons of sugar and 1 tablespoon of salt can be made.

Documentation the patient should carry regarding their disease

One of the essential documents the patient should carry on them is an updated medical report where the generic names for their drugs are included, especially if they are immunosuppressive (corticosteroids, azathioprine, mercaptopurine, methotrexate) or biological treatments. This document is mandatory if the patient is travelling by air as proof of the drugs they are carrying in their hand luggage, so that no problems arise when accessing it. Furthermore, it is advisable that the report be written in English when travelling abroad.

It is also advisable to take drug prescriptions that contain the patient’s full name and surname and their date of birth; the prescription’s issue date; details of the doctor prescribing the drug (name and surname, contact details, license number, specialisation, address and signature); and the details of the prescribed drug (active ingredient, amount, daily dose, regimen, pharmaceutical form and brand name).

Additionally the patient can ask their doctor to prepare an emergency action plan in case they suffer a flare-up during the trip or the disease worsens.

Other documentation that is recommended to always carry on them whilst travelling with ulcerative colitis is the contact number for the doctor treating the patient, their health card (Spanish if it is a domestic trip or European if the destination is a country within the European Union) and the receipt for health insurance purchased for trips abroad covering healthcare in the country they are travelling to. And. specifically, insurance covering possible issues linked to Inflammatory Bowel Disease.

Other aspects to be taken into account when travelling with ulcerative colitis

Recommendations that the patient must consider adopting a preventive attitude in terms of food whilst travelling. Namely, drinking bottled water, boiled or treated for drinking and brushing teeth; not having ice in drinks; avoiding raw food (like vegetables, salads, etc.); not ingesting street food; or peeling fruit. All of this aimed at avoiding a flare-up of ulcerative colitis or a deterioration.

Additionally, emphasis is placed on the importance of locating bathrooms whilst travelling. Especially so the patient feels more confident. To this effect, there are countries like Great Britain where it is easier to find public bathrooms thanks to applications like The Great British Public Toilet Map5, which is very useful for patients with ulcerative colitis and Crohn’s disease, as well as for the general public.

They have also published the IBD Passport6 website (available in Spanish) in this country where travellers with inflammatory bowel disease (IBD) can find further advice and information on the disease.

And if patients with ulcerative colitis need any type of help, they can get in touch with the patient associations that participate in the EFCCA7, the European Federation of Crohn’s & Ulcerative Colitis Associations, whether they are in Spain or in other countries8.

Lastly, they should not forget to ask their doctor about vaccination recommendations9 if they are going to travel to Asian, South American or African countries. Furthermore, if there is a high probability of contracting yellow fever in said country, it is not advisable for the patient to travel to this destination10.

  1. What is ulcerative colitis? – Adacyte
  2. https://www.aegastro.es/publicaciones/publicaciones-aeg/protocolos-asistenciasles-prodiggest/uso-racional-de-la-granulocitomonoaferesis-en-la-enfermedad-inflamatoria-intestinal
  3. Adacolumn® – Adacyte
  4. https://www.aegastro.es/publicaciones/publicaciones-aeg/protocolos-asistenciasles-prodiggest/uso-racional-de-la-granulocitomonoaferesis-en-la-enfermedad-inflamatoria-intestinal
  5. https://www.toiletmap.org.uk/
  6. https://www.ibdpassport.com/
  7. https://www.efcca.org/
  8. http://www.efcca.org/en/members
  9. http://www.vivirconeii.es/viviendo-con-eii/el-estilo-de-vida-importa/viajes
  10. https://www.mscbs.gob.es/profesionales/saludPublica/sanidadExterior/salud/viajesInter/home.htm

News

How to act in case of an outbreak of ulcerative colitis?

July 12, 2022

Patient

Outbreak of ulcerative colitis

To what extent can an outbreak of ulcerative colitis interfere with my future plans? Will those outbreaks have implications for my social and family relationships? What about my professional achievements? What can I do when they show up? These are some of the questions that concern people who are diagnosed with ulcerative colitis. And that is because, although today these patients can have a good quality of life, it is inevitable that they worry about the moments when the symptoms of their illness are activated. That is because their expectations and quality of life will be altered.

To understand what an outbreak is, it is important to know that ulcerative colitis will be silent at many times. In other words, the patient will have remission periods1. However, at other times, the patient will experience abdominal pain, diarrhea, blood in the stools or a sense of urgency.These symptoms warn of a possible outbreak of ulcerative colitis. Depending on the intensity of the outbreak, other systemic symptoms, also called extraintestinal manifestations (EIM), that affect organs and tissues throughout the body, may appear.

Knowing how to act in case of an outbreak of ulcerative colitis is very important to stop the intensity and duration of the episode. The first step will always be to follow the recommendations of our healthcare professionals at all times. They will ensure to handle our case in an effective and personalized way. In addition, we will be conveyed the recommendations at the level of hydration, nutrition, physical exercise, stress and medication that we need. Below we provide some of these tips.

Hydration in outbreaks of ulcerative colitis

Diarrhea is an intestinal disorder that alerts the patient to possible dehydration. This is when we can suspect that the patient is suffering a relapse. In this situation, it is essential to act calmly so as not to increase the intensity of the outbreak.

Some tips for treating diarrhea are:

  • Increase water intake: it can be bottled, boiled or treated.
  • If diarrhea persists for more than one day, it is recommended to take oral rehydration salts (ORS) or, otherwise, a substitute made from 1 liter of bottled water, 6 tablespoons of sugar and 1 tablespoon of salt.
  • If the diarrhea lasts for more than three days and is accompanied by fever, vomiting and blood in the stool, the patient should see a doctor or visit the appropriate inflammatory bowel disease unit.
  • Under no circumstances should medications to stop diarrhea be taken without medical supervision.

Stress influences outbreaks of ulcerative colitis

Stress is not considered a cause of ulcerative colitis, but it can be the trigger for more serious psychological disorders such as depression and anxiety. In fact, these are identified as two of the most prevalent psychological disorders among patients with Inflammatory Bowel Disease (IBD). Some studies have shown that stressful situations or traumatic life events can exacerbate an ulcerative colitis that is in remission. In other words, stress increases the chances of an outbreak2.

In particular, some of the concerns the patients have are: fecal incontinence and the feeling of urgency, fear of having a new crisis, anticipative anxiety of experiencing some episode in public or not performing well at work or academically, among others.

The reverse can happen too: an outbreak of ulcerative colitis may lead to depression or anxiety. In particular, it is estimated that, in active periods (outbreaks) of the disease, these problems can affect 80% of patients3.

In these cases psychological intervention is one of the pillars in the treatment of ulcerative colitis4. By offering tools to adapt to the disease and the new situation, adherence to pharmacological treatment and assistance to controls is favored. Thus, professionals positively influence the reduction of stress and the improvement of the quality of life of patients with ulcerative colitis.

Physical exercise and ulcerative colitis

Leading a healthy lifestyle helps reduce the stress and anxiety caused by the illness itself. They are also important in order to maintain a good functioning of the intestines, and to strengthen bones and muscles. For this reason, walking, swimming, cycling, practicing pilates or yoga, and even doing exercises at home are more than advisable, both in a situation of remission and relapse.

Diet to follow in case of outbreak

For patients with ulcerative colitis in remission, the diet should be as varied and balanced as possible. However, those who suffer an outbreak must modify their diet5 by reducing the intake of:

  • Fiber: whole grains and fresh fruits and vegetables. They should not be completely removed from the diet. They can be consumed baked, steamed or roasted. Basically, the goal is to reduce the chance of having diarrhea and stomach cramps.
  • Saturated fats and sugar.
  • Lactose-containing foods, mainly milk. Its use can be a cause of worsening of symptoms in periods of inflammatory activity. Nevertheless, it is advisable to maintain the intake of dairy products such as yoghurts, which are better tolerated because the milk is fermented.

On the other hand, for patients with weight loss or who suffer from growth and pubertal development retardation it is advisable to lead a hypercaloric diet.

  1. Remission of inflammatory diseases – Adacyte
  2. https://www.sciencedirect.com/science/article/pii/S1873994608000044
  3. https://www.sciencedirect.com/science/article/pii/S0716864019300781#bib0060
  4. https://educainflamatoria.com/bienestar-y-apoyo-emocional/como-afecta-la-enfermedad-inflamatoria-intestinal-a-mi-bienestar-emocional/
  5. Five keys to a proper diet if you have ulcerative colitis – Adacyte

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