There are two leading causes of inflammatory bowel disease; Crohn's disease and ulcerative colitis. Crohn disease occurs in any section of the gastrointestinal tract, while ulcerative colitis occurs in the colon and is mainly exhibited by diffuse mucosal inflammation (Fiocchi, 2018). The significant signs of the inflammatory bowel include celiac disease and irritable bowel syndrome. From the symptoms listed in the case study, it seems that Mrs. Z suffers from a case of inflammatory bowel disease. Therefore, this paper will investigate and describe the best treatment for the 34-year-old female that exhibits symptoms of the disease.
What pharmacologic therapy would you prescribe for Mrs. Z?
I prescribe that the patient be put on anti-inflammatory drugs to treat possible inflammation in her gastrointestinal tract. The patient will use both aminosalicylates and corticosteroids (Ferman et al., 2018). The prescribed dose is 9 mg/day of budesonide (corticosteroid) and 2.8 g/day of mesalamine (an aminosalicylate) for eight weeks.
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I also recommend the patient to use immune system suppressors that will minimize the production of inflammation-inducing chemicals in the gastrointestinal tract. Rather than put the patient on a single drug, I will use a combination of drugs (Colombel, Narula & Peyrin-Biroulet, 2017). The combination will consist of 50mg/day of azathioprine and 50mg/day of mercaptopurine for four weeks.
The patient should also take antibiotics to treat possible infection resulting from the inflammatory bowel disease. Antibiotics reduce the number of bacteria in the gut and alter the composition of intestinal microbiota. For Mrs. Z's case, I recommended the following antibiotics; 1000mg/day of ciprofloxacin and 500mg/day of metronidazole for eight weeks.
Other medication includes iron supplements, pain relievers, and anti-diarrheal medicine. Iron supplements makes up for intestinal bleeding. 1600mg/day of ibuprofen is effective in relieving pain in the abdomen (Colombel, Narula & Peyrin-Biroulet, 2017). 1mg/day of Hyoscyamine Methylcellulose for 5 days is effective in treating diarrhea
How will you evaluate the effectiveness of this therapy?
To evaluate the impact of the pharmacologic treatment, I will carry out a follow-up investigation to observe the action of the drugs regarding the desired goal of the therapy. For instance, I will note the improvement in symptoms and clinical signs by conducting a physical examination and laboratory tests after the first week of treatment. Besides, I will ask the patient if she is experiencing any notable improvements in health, that is, if she is still diarrhoeic and if blood has ceased appearing in her stool.
The follow-up evaluation will also include an analysis of drug toxicity and reactions. For instance, the use of immunosuppressant drugs might lead to adverse drug reactions, i.e., gastrointestinal discomfort, pancreatitis, and hematotoxicity (Krane, Lange & Fichera, 2016). The presence of a drug reaction would mean that the particular drug should be withdrawn and another one prescribed.
Through follow up, I will evaluate the level of the patient’s adherence to the drugs prescribed, and how the adherence or non-adherence is affecting the course of treatment. A significant cause of drug ineffectiveness is non-adherence to treatment. In some instances, it leads to the worsening of the condition (Keshavarzian & Mutlu, 2017). Besides, monitoring adherence enables a medical practitioner to ascertain if the current treatment regimen is effective in treating the disease.
What patient education would you provide for Mrs. Z relative to the pharmacologic agent you prescribed?
I will educate Mrs. Z on how to maintain remission even after completing the prescribed drug therapy. The effectiveness of drug therapy is highly dependent on the attainment of reduction, failure to do so leads to recurring of the disease. Both pharmacological treatment and surgery can lead to permanent healing (Chumanevich et al., 2017). I plan to educate the patient on the importance of sticking to the full course of treatment to prevent possible replace. I would advise her on the long-term use of mesalazine at least 2g/day to complete healing.
I will also advise the patient about the use of contraceptives while exhibiting symptoms of inflammatory bowel disease. Studies show that the use of contraceptives might lead to a 50% increase in the risk of Crohn's disease (Khalili, 2016). Studies also show that the risk of CD increases with the use of contraceptives for long durations but reduces upon discontinuation. Hence, my advice to Mr. Z is for her to speak to her gynecologist regarding other methods of pregnancy prevention. I would advise her to stop using oral contraceptives to prevent the aggravation of her inflammatory bowel disease.
Are there any pharmacogenetic considerations related to what you prescribed for the patient?
Several pharmacogenetic considerations are observed in the drugs used to treat inflammatory bowel and are prescribed for the induction of remission and maintenance of remission in the two types of inflammatory bowel disease (Nickerson & Merchea, 2016). However, the drug has numerous anti-inflammatory effects comprising of platelet aggression, lipoxygenase, and inhibition of acid pathways (Voskuil et al., 2019). Crucial adverse effects include hemolytic anemia, pancreatitis, suppression of the bone marrow, and hypersensitive reactions. Small doses are prescribed for long-term treatment of inflammatory bowel disease since the drug has a short half-life of 7 hours.
Corticosteroids are effective in reducing inflammation. However, they are not as effective in enabling the patient to attain clinical remission. The long-term use of the drugs is discouraged since it leads to clinical relapse and dependency. It also leads to severe infections, glaucoma, the prevalence of diabetes, glucose intolerance, and osteoporosis (Kumar et al., 2011). The best advice regarding the use of corticosteroids is to prescribe the minimum effective dose among patients.
Are there any alternative therapies or over-the-counter agents that might be of value to Mrs. Z?
An alternative therapy often recommend is surgery. Surgery is particularly useful in eliminating damaged or perforated parts of the digestive tract that are responsible for internal bleeding or the presence of blood in the stool. The surgeon removes the damaged part and then reconnects the healthy parts. Surgery is effective in entirely curing ulcerative colitis (Krane, Lange & Fichera, 2016). However, some medical practitioners argue that the benefits of operation are not permanent. They claim that the ailment recurs, especially near the reconnected tissue.
Alternative over-the-counter medications are effective in eliminating the symptoms of inflammatory bowel disease, especially when one has a flare-up. Acetaminophen and anti-diarrhea medication that does not need a prescription to relieve symptoms can be purchased at the local pharmacy (Keshavarzian & Mutlu, 2017). However, if the symptoms fail to change, one might need the intervention of a doctor for effective treatment using antibiotics, corticosteroids, and aminosalicylates.
What, if any, lifestyle changes would you recommend?
Several lifestyle changes are known to alleviate the symptoms of inflammatory bowel disease. Though the changes are not known to prevent inflammatory bowel disease, they help with the regulation of symptoms and increase the time between flare-ups (Nickerson & Merchea, 2016). One should try to avoid certain foods that lead to flaring up of symptoms. For instance, one should limit the use of dairy products and fatty foods. Caffeine, alcohol, smoking, and spicy foods are also known to worsen the symptoms of inflammatory bowel disease. Instead, one should take plenty of water and consume foods that contain lots of fiber, that is, whole grains, vegetables, and fruits (Skrastins & Fletcher, 2018). One is advised to maintain a record of food consumed to establish which food causes symptoms to worsen when taken.
Another recommended lifestyle change consists of physical exercise and relaxation. Exercise is claimed to encourage bowel function, reduce depression, and stress (Fiest et al., 2016). Relaxation techniques assists patients in dealing with muscle tension, anxiety, and stress.
References
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Chumanevich, A. A., Chaparala, A., Witalison, E. E., Tashkandi, H., Hofseth, A. B., Lane, C., ... & Nagarkatti, M. (2017). Looking for the best anti-colitis medicine: A comparative analysis of current and prospective compounds. Oncotarget , 8 (1), 228.
Ferman, M., Lim, A. H., Hossain, M., Siow, G. W., & Andrews, J. M. (2018). Multidisciplinary team meetings appear to be effective in inflammatory bowel disease management: an audit of process and outcomes. Internal medicine journal , 48 (9), 1102-1108.
Fiest, K. M., Bernstein, C. N., Walker, J. R., Graff, L. A., Hitchon, C. A., Peschken, C. A., ... & Bolton, J. (2016). A systematic review of interventions for depression and anxiety in persons with inflammatory bowel disease. BMC research notes , 9 (1), 404.
Fiocchi, C. (2018). Inflammatory Bowel Disease: Complexity and Variability need integration. Frontiers in Medicine , 5 , 75.
Keshavarzian, A., & Mutlu, E. A. (2017). Complementary and Alternative Medicine in Inflammatory Bowel Disease, An Issue of Gastroenterology Clinics of North America, E-Book (Vol. 46, No. 4). Elsevier Health Sciences.
Khalili, H. (2016). Risk of inflammatory bowel disease with oral contraceptives and menopausal hormone therapy: current evidence and future directions. Drug safety , 39 (3), 193-197.
Krane, M. K., Lange, E. O., & Fichera, A. (2016). Ulcerative Colitis: Surgical Management. The ASCRS Textbook of Colon and Rectal Surgery (pp. 869-894). Springer, Cham.
Kumar, A., Auron, M., Aneja, A., Mohr, F., Jain, A., & Shen, B. (2011, August). Inflammatory bowel disease: perioperative pharmacological considerations. In Mayo Clinic Proceedings (Vol. 86, No. 8, pp. 748-757). Elsevier.
Nickerson, T. P., & Merchea, A. (2016). Perioperative considerations in Crohn disease and ulcerative colitis. Clinics in colon and rectal surgery , 29 (02), 080-084.
Skrastins, O., & Fletcher, P. C. (2018). “It Just Is What It Is”: The Positive and Negative Effects of Living with Inflammatory Bowel Disease and Irritable Bowel Syndrome. Clinical Nurse Specialist , 32 (1), 43-51.
Voskuil, M. D., Bangma, A., Weersma, R. K., & Festen, E. A. M. (2019). Predicting (side) effects for patients with inflammatory bowel disease: The promise of pharmacogenetics. World journal of gastroenterology , 25 (21), 2539.
