Pia Prakash

Search with caution: Internet sites target pediatric Crohn's patients with probiotics that often claim to be curative†

We read with interest the article by Marel et al, which revealed that alternative medicine Websites had lower content quality than institutional, pharmaceutical, and nonpharmaceutical commercial Websites as measured by the DISCERN instrument. Inaccuracies on these Websites would likely include information regarding probiotics, as these are among the most common alternative medical therapies. While these products are often used by pediatric Crohn’s disease (CD) patients, there are limited data demonstrating their effectiveness. Lactobacillus GG is the only probiotic that has been studied in children. However, there are conflicting data on the efficacy of Lactobacillus GG. Nevertheless, the potential for effectiveness of probiotics has encouraged its use by pediatric CD patients. This study evaluated the therapeutic claims, bacterial composition, and cost of probiotics marketed for pediatric patients with CD. Using the online search engine Google, ‘‘Crohn’s AND probiotic’’ was searched using Boolean logic. Data were retrieved from July 22, 2009 to July 24, 2009. The first 100 Websites were categorized as either commercial, academic, informational, or as blogs. Commercial Websites were defined as those marketing or selling a product. Academic Websites were defined as those containing scholarly journal articles or textbooks. Informational Websites were defined as sites containing information regarding CD and probiotics, but did not market or sell any products. A blog was defined as a personal chronological log. For each commercial Website, products that were marketed to pediatric patients were identified and the microbial composition was obtained. The first 100 Websites were reviewed. There were nine commercial Websites, 32 academic Websites, 36 informational Websites, and 22 blogs. One Website was not operational. Twenty different probiotics were advertised for sale. Five products were marketed specifically for children and three products were marketed to both children and adults. One product was marketed to adults only, 10 products did not mention a target population, and one product’s information could not be obtained. Of the five products marketed for pediatric use, three were advertised as curative and two were advertised as adjunctive therapy. One of the products advertised as curative claimed to have been clinically studied without providing references. The remaining products did not provide supporting data. The products contained between three and six microbes. None of the five products contained the studied bacteria Lactobacillus GG. Two of the products advertised as curative contained Lactobacillus acidophilus and Bifidobacterium bifidum. None of the other organisms in the advertised products were the same. The two products advertised as adjunctive therapy had six identical organisms. The cost of the products ranged from

Gastroenterologists inconsistently advise against tobacco use in inflammatory bowel disease patients

174 to

Henoch-Schöonlein Purpura Occurring 5 Years After Initiation of Adalimumab: P-9

299 annually. Two of the products’ cost could not be determined based on the provided information. This study found that probiotics marketed to pediatric patients with CD have limited supportive data. While future studies and clinical experience may justify probiotic use in CD patients, presently only Lactobacillus GG has been studied in pediatric patients. Nevertheless, multiple probiotics are available and marketed for the pediatric population with some claiming to be curative. Caution must be exercised when incorporating new products into pediatric medical regimens when there are limited data demonstrating clinical efficacy. Physicians must be knowledgeable of the therapeutic claims of products marketed for children and offer balanced information to pediatric CD patients.

Gastroenterologists May Not Consistently Perform Surveillance Colonoscopies at Recommended Intervals in Individuals With Crohnʼs Colitis: P-87

REFERENCES 1. Friedman S, Cheifetz AS, Farraye FA, et al. Factors that affect adherence to surveillance colonoscopy in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19:534–539. 2. Subramanian S, Klosterman M, Amonkar MM, et al. Adherence with colorectal cancer screening guidelines: a review. Prev Med. 2004;38:536–550. 3. Bernstein CN, Blanchard JF, Kliewer E, et al. Cancer risk in patients with inflammatory bowel disease. Cancer. 2001;91:854–862. 4. Vienne A, Simon T, Cosnes J, et al. Low prevalence of colonoscopic surveillance of inflammatory bowel disease patients with longstanding extensive colitis: a clinical practice survey nested in the CESAME cohort. Aliment Pharmacol Ther. 2011;23:188–195.

High Definition Technology can Enhance Adenoma Detection in Inflammatory Bowel Disease Patients: P-84

toms. She brought in a long list of non-specific complaints. Most notably, her constipation alternating with diarrhea had become more diarrheal-predominant, associated with right lower abdominal pain and a twelve pound weight loss over the last year. Her last screening colonoscopy was normal to the cecum three years ago. Her other medical history includes anxiety, and sigmoid colectomy for recurrent diverticulitis in 1998. She denied use of non-steroidal anti-inflammatory medications. She has a son with ulcerative colitis. Colonoscopy to the terminal ileum showed prior end-end sigmoid anastomosis, an 8 mm polyp 10 cm from the ileocecal valve, and multiple 1-3 mm ulcers in the terminal ileum up to 20 cm from the ileocecal valve. Biopsy showed active ileitis with ulceration, no granulomas or dysplasia. Biopsy of the 8 mm polyp showed well differentiated neuroendocrine neoplasm suggestive of carcinoid tumor. CT enterography revealed no masses or liver lesions. Video capsule endoscopy showed few 1 mm jejunal ulcers, and many 2 mm ulcers throughout the ileum, consistent with small bowel CD. Subsequent ileocectomy confirmed pathologic diagnoses of Crohn’s ileitis and carcinoid tumor (stage IIIB, Ki67 <1%). Coexistence of CD and carcinoid tumor was once thought to be rare. A recent study noted that carcinoid tumors are 15 times more common in patients with CD. The pathogenesis of the two disease association is unclear, but inflammation, pro-inflammatory cytokines, or hyperplasia may play a role in the development of carcinoid tumors, which can even be found in areas with no Crohn’s involvement. Given the similarity in clinical presentation, it is important to be aware of their association, so that carcinoid tumor could be detected and resected prior to metastasis. Optimal management of CD after a diagnosis of malignancy such as carcinoid tumor can also be a challenge. Given the rare coexistence of the two conditions, there are currently no reports to our knowledge on the risk of recurrence with immunomodulators or anti-TNF use in CD after carcinoid tumor resection. Future research on the use of these agents in Crohn’s management after a recent diagnosis of malignancy would be of interest.

Individuals With Inflammatory Bowel Disease May Have Limited Knowledge of the Restroom Access Act: P-95

tinuing tobacco use to control their symptoms. While this study is limited due to sample size and retrospective design with reliance on documentation, it provides a foundation for further research into the complexities of tobacco use and IBD. It is important that a tobacco history be obtained from all patients, that patients are advised of the hazards of smoking, and that tobacco not be considered a therapeutic option in IBD management.

Increased Awareness of the Cervical Cancer Risk and Need for Pap Smears in Women with Inflammatory Bowel Disease Is Necessary: P-96

amines and glucocorticoids, an interruption or cessation of therapy and a delay or change in its use. The routine use of prophylactic therapy is common at many sites despite the fact that these reactions occur in less than 20 percent of patients. However the typical immediate reaction, characterized by facial and chest flushing/anxiety/ shortness of breath, chest tightness, bronchospasm/pruritus and low grade fever is unpredictable in occurrence and may be severe. The routine use of sedating antihistamines and large doses of glucocorticoids to avoid this reaction is associated with inherent side effects such as significant sedation, chronic exposure to steroid therapy, related costs, extension of infusion time and additional costs. These concerns are significant particularly when the use of these medications may be ineffective in many instances. The signs and symptoms of the immediate-type Remicade reaction are unique to this medication and is suggestive of leukotriene pathway activation. METHODS: In consideration of the possible role of leukotrienes as biologic mediators, a protocol was developed utilizing montelukast, a selective leukotriene receptor (CysLT1) antagonist, for those patients who have demonstrated typical Remicade reactions. Thirty seven patients received montelukast, 10 mg on a daily basis for 7 days prior to each infusion and also received a dose immediately prior to the start of the infusion. Prior to montelukast use, fifteen of these patients had previously been pre-treated with diphenhydramine and methylprednisolone as requested by their referring physician and still developed a typical reaction. RESULTS: To date, none of these treated patients have developed a subsequent reaction utilizing this montelukast protocol. These patients have required no other reaction-specific therapy either for prophylaxis or treatment during their infusion CONCLUSION(S): This therapeutic approach had resulted in a significant reduced cost, avoidance of alternative therapy side effects, the maintenance of scheduled patient infusion periods and the ability to maintain the continued effective use of infliximab. Currently, the role of specific leukotriene molecules and activation cascade is being evaluated.

Sleep Dysfunction and Gastrointestinal Diseases.

BACKGROUND: A total of 77 million baby boomers will join the category of elderly over the next 19 years, at a rate of 4 million per year. The elderly inflammatory bowel disease patient is under represented in clinical trials and often clinicians make decisions using data from such trials involving a much younger patient populations. We set out to investigate the safety of 6-Mercaptopurine in our elderly patient population. METHODS: Using an electronic search database we identified 41 patients with Inflammatory Bowel disease on 6-Mercaptopurine/Azathioprine with either Ulcerative colitis (UC) or Crohn’s disease (CD). A comparison of the dosage, side effect profile, and duration of therapy was examined. RESULTS: Of 41 patients with inflammatory bowel disease, 26 were female and 25 were male. The mean age of the patient population was 70.4 years old. Twentyfive patients were diagnosed with CD and 16 with UC. The dosage of 6-MP ranged from 25 mg to 150 mg. The average duration of therapy was 48.5 months. Thirty patients experienced a single side effect, whereas 8 had multiple occurrences. Four patients had to discontinue therapy (1 rash, 1 hepatitis & rash, 1 pancytopenia, 1 infection) secondary to a severe side effect. The other 26 patients continued their therapy at the current dose, or tolerated therapy after lowering dosage. Two patients developed malignancies while on 6-MP(1 Basal Cell Carcinoma& Squamous Cell Skin Cancer, 1 Bladder Cancer & Prostate Cancer). CONCLUSION(S): Our experience demonstrates of 41 patients with inflammatory bowel disease 37/41 (90.2%) were able to tolerate the medication without having to discontinue treatment. Of those with side effects 26/30 (86.7%) were able to continue 6-MP /Azathioprine In our elderly IBD patient population taking immunomodulators that with periodic measurement of CBC, creatinine, and hepatic profile long-term therapy remained beneficial.

Are inflammatory bowel disease patients undergoing surveillance colonoscopies at the recommended time

BACKGROUND: A total of 77 million baby boomers will join the category of elderly over the next 19 years, at a rate of 4 million per year. The elderly inflammatory bowel disease patient is under represented in clinical trials and often clinicians make decisions using data from such trials involving a much younger patient populations. We set out to investigate the safety of 6-Mercaptopurine in our elderly patient population. METHODS: Using an electronic search database we identified 41 patients with Inflammatory Bowel disease on 6-Mercaptopurine/Azathioprine with either Ulcerative colitis (UC) or Crohn’s disease (CD). A comparison of the dosage, side effect profile, and duration of therapy was examined. RESULTS: Of 41 patients with inflammatory bowel disease, 26 were female and 25 were male. The mean age of the patient population was 70.4 years old. Twentyfive patients were diagnosed with CD and 16 with UC. The dosage of 6-MP ranged from 25 mg to 150 mg. The average duration of therapy was 48.5 months. Thirty patients experienced a single side effect, whereas 8 had multiple occurrences. Four patients had to discontinue therapy (1 rash, 1 hepatitis & rash, 1 pancytopenia, 1 infection) secondary to a severe side effect. The other 26 patients continued their therapy at the current dose, or tolerated therapy after lowering dosage. Two patients developed malignancies while on 6-MP(1 Basal Cell Carcinoma& Squamous Cell Skin Cancer, 1 Bladder Cancer & Prostate Cancer). CONCLUSION(S): Our experience demonstrates of 41 patients with inflammatory bowel disease 37/41 (90.2%) were able to tolerate the medication without having to discontinue treatment. Of those with side effects 26/30 (86.7%) were able to continue 6-MP /Azathioprine In our elderly IBD patient population taking immunomodulators that with periodic measurement of CBC, creatinine, and hepatic profile long-term therapy remained beneficial.