Lower GI problems on the up

Crohn’s disease

Crohn’s disease is an autoimmune condition where the immune system starts to attack the gut. This causes inflammation and ulcers anywhere in the gut although it most commonly occurs in the small intestine and colon. Symptoms can include pain, diarrhoea, tiredness and blood in the faeces, but other parts of the body can become inflamed (e.g. eyes, joints or skin). Fatigue, feeling generally unwell, anaemia and loss of appetite are common.

Weight loss occurs due to diarrhoea and poor absorption of nutrients. The diarrhoea can be severe enough to prevent the patient getting to the loo in time. Crohn’s is a lifelong condition and varies through periods of remission where symptoms are largely under control and flare-ups where symptoms are more active.

Treatment is directed at the induction and maintenance of symptom remission. A corticosteroid (e.g. prednisolone, methyl-prednisolone) is used to induce remission or treat a single flare-up in a 12-month period. Azathioprine, mercaptopurine or budesonide can be used as add-on therapy to induce remission, and azathioprine or mercaptopurine to maintain remission. Loperamide or codeine phosphate can be used to treat diarrhoea in those who do not have colitis. Colestyramine is also licensed for diarrhoea in Crohn’s.

Ulcerative colitis

Similarly to Crohn’s disease, ulcerative colitis is an autoimmune condition where the immune system starts to attack the gut but, unlike Crohn’s, ulcerative colitis causes ulcers and inflammation in the colon and rectum only. Symptoms across the two conditions are similar – diarrhoea, cramping pain, need to get to the loo very quickly, blood in the faeces, loss of appetite and weight, anaemia and tiredness.

Symptoms may vary slightly depending on the type of colitis: proctitis is where only the rectum is affected; left side (distal) colitis is where pain is felt on the left side. Total colitis is where pain can be severe throughout the abdomen. Tenesmus, where there is an urge to go to the loo with an empty bowel, is common to all types of colitis.

Like Crohn’s, ulcerative colitis is a lifelong condition, although most people experience times when the condition is largely in remission and flare-ups when symptoms are active. Although ulcerative colitis is a bowel condition, having an overactive immune system and ongoing inflammation can also lead to inflammation in
the joints, eyes or skin.

Management is focused on treating active disease and symptoms while inducing and maintaining remission. Clinical severity and extent of the disease are important factors. A topical aminosalicylate is most commonly used and an oral aminosalicylate if remission is not achieved. An oral corticosteroid should be considered in patients for whom aminosalicylates are not suitable.

Maintenance therapy with an aminosalicylate is recommended to maintain remission. There is no evidence to support the use of methotrexate to induce or maintain remission although it is commonly used in practice.

New treatments for IBD

A range of biologic drugs (e.g. adalimumab, infliximab), Janus kinase inhibitors (e.g. filgotinib) and sphingosine-1-phosphate (S1P) receptor modulators (e.g. ozanimod) are used for maintaining remission of IBD. Others are in the pipeline:

• Etrasimod is an oral S1P receptor modulator, which adheres to a protein on white blood cells stopping them travelling to the gut where they cause inflammation. It is being assessed for the treatment of Crohn’s disease
• Guselkumab is an injectable biologic medicine that works by blocking interleukin (IL)-23, a protein naturally produced in the gut that fights infection but can result in inflammation. NICE is assessing this drug for people who cannot take or have not responded to standard treatments for moderate to severe ulcerative colitis and Crohn’s disease
• Mirikizumab is a biologic that has been accepted by NICE for treatment of colitis and is being assessed for Crohn’s
• Rizankizumab is a biologic accepted by NICE for treating Crohn’s and is being assessed for colitis.

New drug targets for IBD are emerging, including a cellular protein PAK-2 and an immune protein IL-17. A UK research team recently identified a weak spot in the DNA of 95 per cent of patients with IBD, which makes it easier for some immune cells to drive inflammation in the gut. This section of DNA appears to be the main regulator for macrophages and cytokine release, producing inflammation. The researchers found that some people are born with a fault in this part of the genetic code that leads to a huge inflammatory response. Clinical trials could start in the next five years.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a different condition to Crohn’s or colitis, albeit with some similar symptoms. The condition can cause abdominal pain or cramps, but these are often worse after eating and better after passing a motion. IBS also causes bloating, diarrhoea, flatulence, tiredness, nausea, constipation, faecal incontinence, backache and the need to pass urine urgently and frequently. It is more common than irritable bowel disease.

Both Crohn’s and colitis cause inflammation in the bowel and blood in faeces – but IBS does not. Some people with colitis also develop IBS symptoms, and have pain and diarrhoea even when the colitis is not active. IBS is a lifelong condition in which symptoms come and go over weeks and months.

IBS is often triggered or made worse by stress and anxiety. Many IBS sufferers also suffer from anxiety and depression. Understanding how the symptoms affect the patient’s life and providing support to try dietary and lifestyle modifications are key to helping sufferers.

Careful discussion with the patient to exclude more serious conditions is essential. IBS can be managed in pharmacy but only when it has been diagnosed by a GP. 

Refer patients to the GP when there is:

• Persistent constipation (with concomitant weight gain, lethargy, cold intolerance, fatigue, non-specific weakness, aches and pains which could indicate hypothyroidism)
• Persistent diarrhoea (could indicate coeliac disease, inflammatory bowel disease or gastroenteritis)
• Blood in the stools or bleeding, symptoms suggestive of bowel obstruction (vomiting, colicky pain, abdominal distension) or persistent change in bowel habit (i.e. over two weeks or longer) differing from a pattern of going to the toilet over months and years.

Children, pregnant women and patients unresponsive to lifestyle and OTC treatments should also be referred, as should people with any new symptoms.

Diet can help but no one diet suits all patients. The NICE guideline on IBS recommends having a healthy diet with regular meals, adequate fluid intake, limiting high fibre foods such as wheat bran and limiting caffeine. Avoiding sorbitol (found in many food products and diet drinks) can help.

Food intolerances (e.g. dairy, onion, leeks, garlic, fructose) have been implicated in triggering symptoms in some patients. Probiotics can help some patients and advice can be given to try a course for four weeks to see if it makes a difference.

Radical dietary restrictions, including the low FODMAP (short chain carbohydrates that are not fully absorbed in the gut) diet, should not be tried without a dietitian’s guidance as the patient can risk nutrient shortfalls.

Patients should reduce stress as much as possible with regular exercise to contribute to overall well-being.

Various OTC medicines can also help relieve symptoms and improve quality of life.

• Bulk forming laxatives (sterculia, ispaghula) rather than stimulant or osmotic laxatives (as they may aggravate the condition) can help for constipation. Oat bran is also worth a try as it is a soluble fibre and likely to be less of an irritant than wheat bran. Remind the patient to take on more fluids when increasing fibre
• Loperamide for diarrhoea (OTC use in IBS is restricted to patients aged 18 or over and when
  a diagnosis of IBS has been made by a doctor)
• Antispasmodics are available OTC and may be helpful for patients suffering from abdominal pain. Smooth muscle relaxants alverine, mebeverine and peppermint oil and the antimuscarinic hyoscine are used. Side-effects from the smooth muscle relaxants are rare, but hyoscine may cause anticholinergic side-effects (e.g. dry mouth, blurred vision). Efficacy does not vary between antispasmodics but patients often respond better to one than another.

Check dosing and licence restrictions before recommending. Alverine and mebeverine should not be used in children and pregnant women. Peppermint oil should not be used in children. Hyoscine can be used in adults and children over six years (not all brands).

Symptom improvement should occur within a few days so ask the patient to return to the pharmacy after a week to monitor progress. It is worth trying another antispasmodic if the first one has not worked. Patients may need to try several treatments until they find one that suits them. Check what medication the patient has tried and whether it has produced improvement.

Coeliac disease

Coeliac disease is an autoimmune condition driven by immune responses to gluten, which leads to damage of the villi in the lining of the small intestine. Gluten is a complex protein found in wheat, rye, barley, wheatberries, emmer, einkorn, semolina and spelt.

Coeliac disease is characterised and diagnosed by the presence of coeliac-specific autoantibodies and a range of gastrointestinal symptoms of varying severity. Gluten intolerance (or non-coeliac gluten sensitivity) describes an intolerance to gluten with symptoms similar to those of coeliac disease, yet a lack of the same antibodies and intestinal damage as seen in coeliac disease.

Symptoms include diarrhoea with malabsorption causing high levels of fat in the stools (steatorrhoea). Other symptoms include abdominal pain, bloating and flatulence, indigestion, constipation, and vomiting (mainly in children). More general symptoms include fatigue (which may be due to deficiency of iron or vitamin B12), unexpected weight loss, inability to conceive, peripheral neuropathy, oedema of the hands, feet, arms and legs, and disorders affecting co-ordination, balance and speech (ataxia).

Pharmacists should consider the presentation of such symptoms carefully and refer where necessary. An autoimmune reaction to gluten can lead to dermatitis herpetiformis, an itchy skin rash (most commonly on the knees, elbows and buttocks) with blisters that burst when scratched. It occurs in around 20 per cent of people with coeliac disease.

The prevalence of coeliac disease (using serological testing and including previously diagnosed patients) is about 1 per cent in the UK. However, coeliac disease is under-diagnosed. It is estimated that for every person diagnosed, seven to eight remain undiagnosed. The prevalence has increased over the past 50 years (possibly due to improved identification and diagnosis). Coeliac disease affects all age groups, including older people, with 70 per cent of new cases diagnosed in people over the age of 20 years.

The only effective management for coeliac disease is long-term adherence to a gluten-free diet. This can be a difficult for patients to follow and children will need extensive support. Referral to a dietitian can help to educate the patient and check for any nutritional deficiencies (e.g. vitamin B12, vitamin D, iron and calcium).

Pharmacy teams can support patients with their prescriptions for gluten-free products ensuring availability of stocks with as much choice as possible. Dietary advice is essential so that gluten-containing foods are avoided.