What’s new in IBD treatment? Advances in the Medical and Dietary Management of IBD
A webinar summary moderated by Janie Yang, MD, paneled by Asher Kornbluth, MD and Faith Aronowitz, MS, RD, CDN
Inflammatory bowel disease (IBD) is a chronic and complex disease that affects millions of people worldwide. It can lead to irreversible damage to the bowels if not adequately managed, making inflammation control crucial for patients with Crohn’s disease and ulcerative colitis. In this webinar review, we will explore the effectiveness and safety of various treatments for IBD, including new drug treatments like Zeposia, Rinvoq, and Skyrizi, biologics, infusion therapies to name a few. We will also discuss the importance of measuring inflammation, potential adverse side effects of medications, and how Rinvoq works for moderate to severe disease patients.
Faith Aronowitz, MS, RD, CDN, is a registered dietician who believes in using a weight-inclusive non-diet approach to care. As an expert in gastrointestinal health and eating disorders, she has experience working with a diverse range of patients.
Asher Kornbluth, MD, on the other hand, is a medical educator and clinician with years of experience under his belt. He has published numerous articles, book chapters, and invited editorials, and is the principal author of the first three editions of the Ulcerative Colitis Practice Guidelines in Adults, published by the American College of Gastroenterology.
New Drug Treatments for Crohn’s Disease and Ulcerative Colitis
When it comes to treating Crohn’s disease and ulcerative colitis, it’s not just about dealing with the symptoms. Doctors must also take into account the risks of the medications they prescribe. Fortunately, we have new drug treatments available. The drugs they will be speaking about include Zeposia (Ozanimod, Rinvoq (Upadacitinib), and Skyrizi (Risankizumab).
Why inflammation control is crucial in Crohn’s and Ulcerative Colitis
Crohn’s and ulcerative colitis are inflammatory bowel diseases that can become progressively worse if not adequately treated. Patients are not just concerned about feeling better but avoiding hospitalization, complications, and surgery. Uncontrolled inflammation can lead to irreversible bowel damage, so it’s crucial to control it. We used to think that asking patients how they felt was the only way to measure disease progression, but we now know that patients can have objective measures of inflammation even if they have no symptoms.
The importance of measuring inflammation in Crohn’s and Ulcerative Colitis
Different measures can help assess inflammation, such as colonoscopy, blood tests, and fecal calprotectin. Fecal calprotectin is one of the most accurate and sensitive measures of active inflammation. It is reflective of active inflammation, and it’s quantitative, which means you can follow it over time to see how treatment is working. The goal is to achieve a score within a specific range, and patients whose scores do not improve may need more active intervention. Therefore, measuring inflammation helps physicians identify the most appropriate treatment strategy.
Effectiveness of Infusion Treatments for Crohn’s Disease and Ulcerative Colitis
What is an infusion treatment?
Infusion treatments for Crohn’s Disease and Ulcerative Colitis involve IV injections of drugs that have been through rigorous clinical trials. Patients receive their first infusion at week four and see a clinical response by their second dose. The improvement continues out to week eight when patients receive their third dose and by week 12, patients receive their first injection. These drugs have been studied for one year and are FDA approved. Patients in clinical trials are randomized and given either the drug or a placebo, with neither the doctor nor patient knowing which treatment they’ve received.
Induction and Maintenance stages
Infusion treatments have two phases: the induction phase and the maintenance phase. During the induction phase, patients receive a dose for a specific period. The clinical response during the induction phase is measured by looking at a patient’s symptoms, which should have improved significantly. The drug also needs to show it can maintain patient improvement for a year before it is FDA approved.
The maintenance phase is when patients are monitored for a year to ensure the drug is still working correctly. Infusion treatments for Crohn’s disease and ulcerative colitis have been studied in about 1,500 patients for one year. Therefore, it’s essential to keep in mind that rare complications, such as lymphoma, might not show up in studies of this size. These drugs are approved for patients who have not started biologic drugs and have been previously untreated.
Effectiveness of Biologics in Treating Crohn’s Disease
Biologic-naive vs. Biologic-experienced patients
Before starting on biologics, most patients want to know whether it’s effective in treating their Crohn’s disease. When it comes to biologics, studies usually look at two types of patients: biologic-naive and biologic-experienced. Biologic-naive patients are those who haven’t tried biologics before, while biologic-experienced patients are those who have tried drugs such as Remicade, Humira, Stelara, or Tivio.
Some people might think that biologic-experienced patients won’t benefit as much from biologics because they have already tried similar drugs. However, it’s important to note that biologic-experienced patients are usually sicker and have more severe symptoms compared to biologic-naive patients. While biologic-experienced patients may not respond as frequently, studies have shown that both groups benefit from biologics.
Concerns about side effects
One major worry patients have when considering biologics is the potential for side effects. Many people associate biologics with drugs like Remicade or Humira, which have been reported to increase the risk of lymphoma. However, it’s important to note that not all biologics come with such risks. Newer biologics like Stelara or Tivio are remarkably safe, with no increased risk of infections or lymphoma.
It’s also important to remember that just because a drug is considered a biologic, it doesn’t mean it’s dangerous. All it means is that the drug was prepared in part in a living cell. Old-fashioned insulin, for example, is a biologic drug that has been around for decades. Studies have shown that biologics like Skyrizi are actually associated with fewer severe adverse events and infections compared to a placebo. This could be because getting better with a biologic may reduce the need for other drugs that increase the risk of complications. Overall, biologics can be an effective and safe option for managing Crohn’s disease symptoms.
The Limitations of Current Ulcerative Colitis Treatments
A Look at Common Medications
When it comes to treating ulcerative colitis, there’s no one-size-fits-all treatment. Many patients will try a combination of medications before finding what works for them. Unfortunately, even our best medications have limitations.
One of the most common medications for ulcerative colitis is prednisone, a steroid. While effective at quickly reducing inflammation, it’s not a long-term solution. If patients become dependent on it, they’ll likely need to switch to another medication. Additionally, biologics, newer drugs that target the immune system, can work wonders for some patients but have limitations. They don’t work for 100% of patients, and even when they do work, they may only work for up to two-thirds of patients.
What is Zeposia?
Zeposia is a new oral drug for moderate to severe ulcerative colitis. It is in the family of S1P modulators. S1P stands for Sphingosine 1-Phosphate which is throughout the body, including the nervous system, and blocking it helps in multiple sclerosis. Ozanimod is the key ingredient in Zeposia. It helps in blocking the activation of white blood cells that cause inflammation. Once the white blood cells are blocked, it gets trapped in the local lymph node, and it cannot head towards the intestines to cause inflammation. This leads to symptom relief and remission.
How effective is Zeposia?
Symptomatic relief happens as early as week two, in terms of bleeding and the frequency of stool. There is a gradual improvement in the symptomatic response curve that continues to improve until week 10. Remission, meaning getting entirely back to normal, takes longer than symptomatic relief. The remission does not happen as quickly, but there is a significant improvement, which can be seen by the end of the 10th week.
Effectiveness of Medications
One important factor in ulcerative colitis treatment is the effectiveness of medications. As shown in the study, it takes about four weeks for the active drug to start taking effect, with patients showing the most improvement in remission after a year of treatment. It’s important to note that if a patient is still using corticosteroids after this time, it’s considered a failure and they need to try a different approach.
Safety of Medications
When considering the safety of medications, it’s important to weigh the risks against the benefits. In the case of ulcerative colitis, the newest drug available, a JAK-kinase inhibitor called Rinvoq, has already been approved for other conditions like rheumatoid arthritis and psoriasis. The study showed that adverse events were minimal with this medication and patients had a low drop-out rate compared to the placebo group. This suggests that the medication is safe to use for long-term maintenance of remission. It’s important to make sure patients are aware of these options and to work with their doctors to find the most effective and safe treatment plan.
What is Rinvoq?
Rinvoq is an oral medication used to treat patients with moderate to severe diseases like psoriasis and rheumatoid arthritis. It’s a once a day pill, not a biologic, and has high response and remission rates in patients with rectal bleeding. In fact, it has the highest response and remission rates of any drug we have, even though it’s just a pill.
Studies have shown that Rinvoq works quicker than any other drug we’ve had, save maybe prednisone and maybe Remicade. Patients on Rinvoq have much higher remission rates than placebo. This is important because patients who have moderate to severe diseases need quick and effective treatment options. Rinvoq has been proven to be a more effective and cheaper alternative to other treatments.
Potential Adverse Side Effects of Rinvoq
Rinvoq, like most immunosuppressive drugs, has potential side effects such as infections and the suppression of the immune system. However, studies have shown that patients on Rinvoq had less adverse events leading to discontinuation of study drugs and fewer infections than placebo. This is important information to keep in mind, but it’s ultimately up to patients and their healthcare providers to weigh the benefits and risks of any medication before deciding on a treatment plan.
Nutrition and Inflammatory Bowel Disease
Diet plays a significant role in both the development and management of inflammatory bowel disease (IBD). Recent studies have shown that dietary patterns can affect the gut microbiota, which may influence inflammation in the body. In addition to dietary patterns, fiber intake and specific foods elimination have been found to improve symptoms and reduce inflammation in patients with IBD. However, it is crucial to work closely with healthcare providers or registered dietitians to develop a personalized nutrition plan.
Research has shown that a low fiber diet may actually do more harm than good for patients with IBD. In fact, a diet that includes both soluble and insoluble fiber has been shown to improve symptoms and reduce inflammation. Soluble fiber is found in foods like oats, beans, and fruits, and can help to soothe and coat the intestines. Insoluble fiber is found in foods like vegetables and whole grains, and can help to add bulk to the stool and improve bowel regularity. It’s important for patients with IBD to gradually increase their fiber intake and drink plenty of water to avoid any discomfort.
In addition to fiber, there are some other dietary changes that may benefit patients with IBD. Eliminating certain foods, such as dairy, gluten, or specific types of carbohydrates, may help to reduce symptoms and inflammation. An elimination diet, under the guidance of a healthcare provider or registered dietitian, can help to identify trigger foods that may need to be avoided. It’s also important for patients with IBD to maintain a well-rounded and balanced diet to ensure they are getting all the necessary nutrients. Supplements may be needed if there are any nutrient deficiencies.
Overall, while diet alone cannot treat IBD, it can certainly play a role in both the development and management of the disease. Making certain dietary changes, like increasing fiber intake and eliminating trigger foods, can help to improve symptoms and reduce inflammation. It’s important for patients with IBD to work closely with their healthcare provider or registered dietitian to develop a personalized nutrition plan.
The Link Between Diet and IBD Development
There have been numerous studies in the past few years that suggest that diet can actually increase the risk of developing IBD and can also be used as an adjunctive therapy to maximize the effectiveness of medication. It is important to note that diet should not replace medical treatment. Recent research has focused on the gut microbiota and how dietary patterns affect the gut microbiota and their interaction with the immune system, which may influence inflammation in the body.
Specific Foods and the Risk of Developing IBD
One particular study tracked the dietary habits and health outcomes of 116,000 people over nine years and showed that the more servings of ultra-processed food consumed daily, the greater the risk of developing IBD. Ultra-processed foods are foods that contain few, if any, ingredients that come directly from natural plant or animal foods. This includes foods such as soda, sweetened breakfast cereals, packaged cookies, packaged white breads, hamburger and hot dog buns, and artificially flavored cheese crackers. People who consumed five or more servings of ultra-processed food daily had an 82% greater risk of developing IBD compared to those who consumed less than one serving of ultra-processed food per day.
The Role of Fiber in the Treatment of IBD
In the past, a low-fiber diet was recommended to patients with IBD. However, recent research suggests that fiber may actually have a positive effect on IBD. Fiber helps to promote bowel regularity and can improve stool consistency. It also helps to nourish the gut microbiota and may have an anti-inflammatory effect on the intestine. This means that the inclusion of fiber in the diet of patients with IBD may be beneficial. However, it is important to start with small amounts and to gradually increase fiber intake. Patients with IBD may have difficulty tolerating certain types of fiber, so it is important to work with a healthcare provider to determine an individualized treatment plan.
The Importance of Dietary Fiber in IBD Treatment
Fiber and Gut Microbes
Multiple studies have shown that increasing dietary fiber intake can be beneficial for people with inflammatory bowel disease (IBD). This is because fiber can help to reduce flares, increase the time between flares, and reduce the instances of pouchitis in people with ulcerative colitis. One way fiber achieves this is by nourishing our gut microbes with the fiber we consume. The gut microbes then produce short-chain fatty acids, which are anti-inflammatory compounds that help to create a less inflammatory environment in the gut.
Soluble vs. Insoluble Fiber
There are different types of dietary fiber, and it’s essential to understand which ones are better for people with IBD. Soluble fiber found in fruits and veggies tends to be more easily digestible than insoluble fiber. In times of flare-ups or stricturing, modifying the texture of fiber can be helpful. The key is to blend it into a smoothie or soup to make it easily digestible and avoid aggravating inflamed tissue in the gut.
Enteral Nutrition as a Primary Treatment
While there isn’t much evidence to suggest that diets alone can replace medication for treating IBD, exclusive enteral nutrition (EEN) has shown promise as a primary treatment. EEN involves the temporary avoidance of all solid foods and instead consuming nutritionally complete liquid meal replacements, such as Ensure or Boost, for six to twelve weeks. Partial enteral nutrition (PEN) is another type of enteral nutrition in which some solid nutrition is replaced with liquid meal replacements. Studies have shown that combining PEN with medication can double the chances of inducing disease remission in people with Crohn’s.
Recommended Dietary Patterns
The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) 2020 guidelines recommend dietary patterns for people with CD and UC based on the best available evidence. The recommendations include consuming a diet rich in fruits and veggies, fiber, and omega-3 rich foods like fish and flaxseed. The guidelines also advise people with IBD to minimize processed foods, high-fat foods, and red meat., Specific Carbohydrate Diet (SCD)
The Specific Carbohydrate Diet, or SCD, is a diet plan that has been around for almost a century. It is a grain-free, lactose-free, low-sugar diet that eliminates practically all processed foods. What is allowed in this diet are animal proteins, nuts, fruit, non-starchy veggies, sunbeans and legumes, and lactose-free dairy. Though the diet may be a challenge to follow as it restricts packaged food intake and requires meals cooked from scratch, it has been shown to reduce IBD symptoms in some cases.
Mediterranean Diet (MED)
The Mediterranean Diet, or MED, is a more flexible diet that encourages plant-based foods, including whole grains, beans, legumes, and seeds, among others. It also promotes the consumption of heart-healthy unsaturated fats such as avocados, nuts, seeds, olive oil, and fatty fish. This diet is less restrictive, making it easier to integrate into daily life and sustain over time.
According to a recent study, the MED and SED diets are comparable in their ability to alleviate symptoms of Crohn’s disease. This outcome implies that it may be worthwhile to consider the MED diet as the preferred option for alleviating IBD symptoms.
The Mediterranean diet has been associated with several health benefits, including reduced cardiovascular disease, type 2 diabetes, colorectal cancer, Alzheimer’s disease, and breast cancer. The diet emphasizes whole foods and minimizes ultra-processed foods, which is essential for managing symptoms and decreasing inflammation overall. Unlike the specific carbohydrate diet (SCD), the Mediterranean diet encourages the consumption of fruits, veggies, and fiber-rich foods, all of which have anti-inflammatory properties.
Fiber is a key component of the Mediterranean diet and should be used to manipulate the physical properties of fibrous foods to improve digestive health. The diet is an excellent tool to help manage IBD symptoms and should be used in conjunction with medical treatment to limit the chances of complications. It is vital to remember that there is no universal diet recommendation for IBD, and consulting a nutrition team for individualized recommendations is important.
Supplements should be used when necessary to manage side effects of medications and replete any nutrient deficiencies. Curcumin, the active ingredient in turmeric, is a supplement that has shown effectiveness but requires more research.