OTC Case Studies: Inflammatory Bowel Disease

CASE 1: VITAMIN D FOR CROHN DISEASE

Q: GN is a 21-year-old man with a close relative who has inflammatory bowel disease (IBD). GN has heard about the potential protective effects of vitamin D supplementation for Crohn disease development. Although he has not developed Crohn disease, he is aware that his risk for development of the disease is 4 to 20 times higher because of genetics. What information can the pharmacist provide regarding vitamin D supplementation in Crohn disease?

A: The results of several studies have shown vitamin D deficiencies in patients with IBD. However, a causative relationship with vitamin D deficiency and onset of IBD has not been established in studies. The study results do show that vitamin D deficiency is more common in individuals with Crohn disease and ulcerative colitis (UC) than in the general population. Theoretical explanations for the protective effects of vitamin D have been established. Vitamin D regulates proteins that are involved in the maintenance of the gastrointestinal barrier. As such, vitamin D may be associated with protection of the gut microbiota. Another well-known property of vitamin D is its ability to ameliorate inflammation. With both the barrier protection and anti-inflammatory properties, vitamin D is thought to slow disease progression of IBD.^1-3

Experts suspect the vitamin D deficiency in IBD may be correlated to its mechanism, including decreased exposure to the sun, impaired gastrointestinal absorption of nutrients, and restricted dietary intake.^1-3

CASE 2: ANTIDIARRHEAL FOR UC

Q: JM is a 33-year-old man with ulcerative colitis (UC) who is having more frequent and looser bowl movements. He is also experiencing abdominal cramping and has asked his fiancé to pick up antidiarrheals, as they are on vacation and have lost track of JM’s medication. What guidance can the pharmacist offer on loperamide for UC, including the administration, adverse effects, dosing, mechanism of action, and warnings?

A: Loperamide (Imodium) is an antidiarrheal that works by binding to mu opioid receptors on intestinal neurons, leading to decreased gastrointestinal (GI) motility and loss of electrolytes and fluids. Loperamide decreases fecal volume while increasing viscosity of stool. Loperamide also has been thought to increase anal sphincter tone, which may lead to improved fecal continence. The adverse effects of loperamide are primarily related to the GI mechanism: abdominal pain, bloating, constipation, nausea, and vomiting.⁴

The pharmacist should offer counseling on loperamide dosing. Patients should take 2 mg after each loose stool, up to a maximum of 16 mg per day. At typical therapeutic doses, loperamide does not cross the blood-brain barrier, but when supratherapeutic doses are taken, loperamide may cross the blood-brain barrier and cause opioidlike effects. At higher-than-recommended doses, loperamide may lead to life-threatening cardiac adverse events, including arrythmias, QTc prolongation, sudden death, and syncope.⁴

CASE 3: VACCINATIONS AND IBD

Q: PJ is a 27-year-old woman who is on immunosuppressive therapy for inflammatory bowel disease (IBD). She wants to speak to the pharmacist about vaccinations. PJ’s physician had recommended vaccines but she is unclear about her needs. What vaccines should the pharmacist recommend to PJ?

A: Given that PJ is on immunosuppressant therapy, it should be noted that the overall response to vaccinations may be suppressed by the IBD medications. Even so, patients with IBD on immune system suppressing medications should be vaccinated against infections as they are at a higher risk of contracting them. All patients with IBD should receive only nonlive vaccines, as their immunosuppressed state puts them in danger of infection from strains of live virus or bacteria from the vaccines, according to the Advisory Committee on Immunization Practices of the CDC and the Infectious Diseases Society of America.^5,6

Adult patients with IBD should receive the annual inactivated influenza intradermal or intramuscular vaccine. Evidence suggests that patients with IBD who develop the influenza infection are more likely to be coinfected with pneumonia and hospitalized. Patients with IBD on immunosuppressants should receive the pneumococcal conjugate vaccine, followed by the pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later. PPSV23 should be repeated 5 years after the first dose and once again after age 65. For hepatitis vaccines, a patient’s immunity should be assessed via blood work. If the patient’s titers confirm that she is not immune to hepatitis A, a 2-dose series should be administered, with the second dose 6 to 12 months after the first. Similarly, if the patient’s titers confirm that she is not immune to hepatitis B, a 3-dose series should be administered, with the second and third doses occurring 1 and 6 months after the first dose, respectively. Patients with IBD who are older than 50 years should receive the nonlive herpes zoster vaccine, Shingrix.^5-7

CASE 4: CIGARETTE SMOKING AND IBD

Q: SP is a 37-year-old man with Crohn disease. He has been on immunosuppressant medications for Crohn disease but has not been able to quit smoking. SP has questions about smoking, including that he has heard that smoking is protective, and if he quits smoking, his inflammatory bowel disease (IBD) will flare up and his symptoms will be worse. What information should the pharmacist provide to SP?

A: Data suggest that for patients with IBD, smoking is associated with the development and progression of the disease as well as poor outcomes. The results of a meta-analysis and several studies show a significant increased risk for development of Crohn disease. Moreover, some study results show that smoking is related to poor response to IBD treatment.^8-12

Additionally, the results of a prospective study of patients with Crohn disease showed that after smoking cessation, the risk of IBD flare-ups in those who quit smoking did not differ from that of those who were nonsmokers and was lower than in those who continued smoking. Encourage SP to quit smoking.^{8, 9}