Transcript Dias nummer 1

Mikroskopisk colitis
Fagligt Selskab for Gastroenterologiske sygeplejerkser
Landskursus, Kolding
16. November 2012
Ole Bonderup, Medicinsk afdeling, Regionshospitalet Silkeborg
Mikroskopisk colitis
Mikroskopisk colitis
Lymphocytic Colitis
Collagenous Colitis
(Lindström, 1976)
(Read et al.1980)
(Lazenby et al., 1989)
Microscopic
Colitis
Ole Bonderup, Medicinsk afd. Regionshospitalet Silkeborg
Mikroskopisk colitis
Colitis ulcerosa
Mikroskopisk colitis
Mb Crohn
Mucosal tears in collagenous colitis
Allende DS et al. Am J Gastroenterol 2008
Mikroskopisk colitis
It´s best to know what you are looking for before you look for it
Normal colon mucosa
Collagenous colitis
Lymphocytic colitis
Mikroskopisk colitis
MC versus non MC
Interobserver agreement 91% (kappa = 0.90)
Intraobserver agreement 95% (kappa = 0.89).
Limsui D, et al Inflamm Bowel Dis. 2009
Epidemiologi
Mikroskopisk colitis - epidemiologi
CC
LC
Sweden 1984-93
9.0/1
---
Spain 1993–97
4.8/1
2.7/1
Sweden 1993-98
7.5/1
2.1/1
US 1994-01
6.7/1
1.6/1
Iceland
7.9/1
5.0/1
Female/male ratio
Incidence of collagenous colitis.
Annual incidence per 100.000 inhabitants
Örebro, Sweden
1984-88
1989-93
1993-95
1996-98
Olmsted County,
1985-89
1990-93
1994-97
1997-2001
Incidence of lymphocytic colitis
Annual incidence per 100.000 inhabitants
Örebro, Sweden
Olmsted County,
1985-89
1993-95
1996-98
1999-04
1990-93
1994-97
1998-01
Symptomer
Mikroskopisk colitis
F Baert et al, Gut 1999
Mikroskopisk colitis
• Hovedsymptomet ved mikroskopisk colitis er
et svært diaré-problem.
• Hyppigt et meget langvarigt diaré-problem
• Afføringen beskrives som vandtynd op til 10 15 gange i døgnet.
• Der er ofte pludselig indsættende og
uimodståelig afføringstrang.
Mikroskopisk colitis
• Der er sædvanligvis ingen ”advarselssymptomer”
• Ingen blod i afføringen
• Intet større vægttab
• Ingen væsentlige smerter
Er dette tilfældet skal andre sygdomme
overvejes
Mikroskopisk colitis - symptomer
• Svære afføringsgener
•
•
•
•
Diaré
Natlig afføring
Imperiøs afføring
Incontinens
• Lette almensymptomer
• Vægttab
• Mavesmerter
• Meteorisme
Ole Bonderup, Regionshospitalet Silkeborg
Livskvalitet
Mikroskopisk colitis - livskvalitet
Hjertesorg er svær at bære
Mavekneb det er dog værre
Piet Hein
Mikroskopisk colitis - livskvalitet
Kronisk diaré
=
Dårlig livskvalitet
Mikroskopisk colitis – livskvalitet
Quality of life (SF-36) in patients with collagenous and lymphocytic colitis.
CC. N=38
56.2
LC. N=13
74.4
Controls
85.7
Role limitation –
physical
35.2
56.2
83.7
Bodily pain
46.7
45.4
58.3
58.3
79.1
68.1
Role limit –
emotional
41.6
52.5
63.3
Vitality
56.2
55.5
56.0
79.2
83.3
74.3
88.8
90.3
73.9
Physical funct.
General health
Mental health
Social functioning
Miehlke et al.
Ole Bonderup, Medicinsk
afd.Regionshospitalet Silkeborg
Mikroskopisk colitis– livskvalitet
H. Hjortswang, 2005
Etiologi
Kollagen colitis - etiologi
Importance of
intraluminal
agencies
?
Drugs
Bile
acids
Bacteria
Food
?
Behandling
Mikroskopisk colitis
• Ubehandlet har sygdommen ofte et langvarigt
kronisk forløb.
• Almentilstanden er relativ upåvirket, men
sygdommen påvirker i svær grad livskvaliteten.
Collagenous colitis - background
Retrospective evaluation of treatment in collagenous colitis.
No. of pts.
Effect
No effect
Adv. effect
Sulphasalazine
108
37
26
45
Mesalazine
16
8
8
0
Olsalazine
15
4
6
5
Prednisolone
39
32
6
1
Budesonide
2
2
0
0
Metronidazole
44
24
16
4
Erythromycin
15
10
4
1
8
8
0
0
Cholestyramin
44
26
17
1
Loperamide
69
49
18
2
Penicillin
Bohr et al. Gut, 1996
Kollagen colitis
Dobbelt-blind undersøgelse
Budesonide treatment of
collagenous colitis
Long-term budesonide
treatment of collagenous
colitis
Budesonide
Chemical structure of budesonide
Kollagen kolitis
• Budesonide
– Steroid med lokal virkning
– Frigøres i terminale ileum
– Høj affinitet for steroid receptore
– High first-pass metabolisme i leveren
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
Kollagen colitis
Budesonide treatment of collagenous colitis.
Study design of the 8 week randomised, double-blind, placebo-controlled trial.
Budesonide
n = 10
R
Placebo
n = 10
Double-blind
treatmente phase
8 weeks
R, randomisation
Double-blind follow-up
(off treatment)
8 weeks
Budesonide treatment of collagenous colitis.
Results of the 8 week randomised, double-blind, placebo-controlled trial.
Clinical effect
+ effect
- effect
Budesonide (n=10)
10
0
Placebo (n=10)
2
8
P<0.001
Kollagen colitis
Budesonide
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
Kollagen colitis
Kaplan-Meier curve of the risk of relapse after 8 weeks budesonide
treatment .
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
Kollagen colitis
Long-term budesonide treatment of collagenous colitis.
Study design of the 54 week randomised, double-blind, placebo-controlled trial.
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
Kollagen colitis
Double-blind
maintenance phase
6
Budesonide
6 mg once daily
Placebo
30
Double-blind follow-up
(off treatment)
54 weeks
17
13/17 (76.5%)***
4/17 (23.5%)
17
2/17 (12%)
2/17 (12%)
***p<0.001 versus placebo (Fisher’s exact test)
Kollagen colitis
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
Kollagen colitis
Budesonide
10%
100%
Pharmacokinetic of budesonide
Ækvieffektive forhold budesonid versus prednisolon
Budesonid (Entocort)
Prednisolon
Klinisk effekt ved
aktiv Crohn’s sygdom . . . . 9 mg p.o.
40 mg p.o.
Påvirkning af
binyrebarkfunktionen . . . . . 9 mg p.o.
6 mg p.o.
Kollagen colitis - behandling
• NSAID
– NSAID seponeres.
• Kost
– Nedsætte kaffe forbrug
• Anti-diaré behandling.
– HUSK
– Imodium
– Questran
Ole Bonderup, Medicinsk afd. M1,
Regionshospitalet Silkeborg
Kollagen colitis -behandling
• Budesonide
– First-line behandling i 8-12 uger
• 9 mg 1x dgl i 2 - 4 uger
• 6 mg 1x dgl i 2 - 4 uger
• 3 mg 1x dgl i 4 - 8 uger
– Ved recidiv behandling i 24 uger
– Omkring 30% har behov for langtidsbehandling
Ole Bonderup, Medicinsk afd.
Regionshospitalet Silkeborg
EMCC Consensus Treatment of Microscopic Colitis
MC established
Drug-induced colitis
?Consider drug
Dietary recommendations*
withdrawel*
quit smoking
mild symptoms
i.e. antidiarrheals
+/- cholestyramine*
asymptomtatic
 no Tx
moderate/severe symptoms*
Budesonid 9 mg/ for 6-8 weeks
failure
relapse
failure
Alternative drugs
Aminosalicylates
+/- Cholestyramin
Bismuth
Probiotics
failure
mild/moderate
symptoms
severe
symptoms
Retreatment with
Budesonide*(intermittend,
continous)
+ Calcium/Vitamin D
Immunomodulators
relapse, intolerance
i.e. AZT, MTX
failure
Surgery