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Northeast Florida Medicine
Vol. 66, No. 4 2015
57
CME
with lifestyle modifications, vitamin D supplementation
(800 – 1000 IU daily), calcium citrate (1200mg daily)
and pharmacological therapy, such as bisphosphonates.
6
Vaccinations
Because of their disease, chronic inflammation, nu-
tritional deficiencies and use of immunosuppressive
medications, patients with IBD are at increased risk for
many infectious diseases that can be prevented by proper
vaccination. Please refer to the article on vaccinations in
this journal.
Treatment of depression, anxiety and
screening for abnormal body image
Whether anxiety, depression, stress or certain personality
types are predisposing factors for IBD is still unproven
and controversial.
7
What is clear is that depression and
anxiety are more prevalent in patients with IBD.
8
Symp-
toms are often worse during disease flares. Health related
quality of life outcomes and disease progression is worse
in affected patients. Use of corticosteroid medications is
a risk factor. Patients with IBD should be screened for
anxiety and depression and treated with pharmacological
and/or psychotherapeutic measures to obtain the best
outcomes.
9
Body Image is defined as a person’s sense of their phys-
ical appearance and bodily function. Recent studies have
shown a high prevalence of body image dissatisfaction in
patients with IBD, especially in females and those who
have had surgery with or without a stoma.
10
Some experts
advocate routine screening for abnormal body image.
11
Monitoring for and
treating nutritional deficiencies
Protein calorie malnutrition and macronutrient de-
ficiency is less common in adults with IBD compared
to the pediatric population. However, deficiencies of
micronutrients are fairly common and the PCP plays an
important role in diagnosis and treatment. Deficiencies
can occur due to decreased intake, decreased absorption
due to disease or surgery, and increased losses from di-
arrhea or bleeding.
1,12
Folate deficiency is common, and is seen in 20-60
percent of patients.
12
Decreased dietary intake of folate
and the use of sulfasalazine and methotrexate are risk
factors. Vitamin B12 deficiency is seen in 25 percent of
patients and patients with gastritis, terminal ileal disease
and/or resection are at risk.
13
Niacin deficiency is seen
in 25 percent of patients, but pellagra is uncommon.
Deficiency of fat-soluble vitamins like vitamin A, D,
E and K is seen in patients with Crohn’s disease, with
fat malabsorption, and with cholestyramine use. Iron
deficiency is particularly common, with a prevalence
of 35 to 90 percent.
14
In patients with active disease, a
ferritin level of below 100 is suggestive of iron deficiency,
as ferritin is an acute phase reactant. Many patients are
intolerant or unresponsive to oral iron and may require
IV iron for adequate replacement. IV iron is preferred in
Europe for treating IBD patients.
15
Zinc deficiency is seen
in 65 percent of patients, particularly in patients with an
ostomy, diarrhea or fistulas.
12
Other mineral deficiencies
including selenium, copper and magnesium can be seen.
Patients with IBD should take a multivitamin with min-
erals daily. Routine lab work can screen for micronutrients
and replacement can be initiated when a deficiency is found.
NSAIDS and IBD
While subclinical nonsteroidal anti-inflammatory drug
(NSAID) induced injury to the gut is common, symptom-
atic disease is uncommon. NSAIDs can cause erosions,
ulcerations, strictures, diaphragms and colitis, which can
sometimes mimic IBD.
1,16
NSAIDs can also precipitate
preexisting IBD. Long term NSAID use appears to be
the most risky.
17
These lesions resolve after NSAID use is
discontinued and this is one way to distinguish NSAID-in-
duced lesions from lesions due to IBD.
18
COX 2 (Cyclo
OXygenase 2) inhibitors also carry the same risks, but
somewhat less than non-selective NSAIDS.Tylenol, topical
NSAIDs and tramadol appear to be safe alternatives for
pain control. Narcotics do not exacerbate IBD, but carry
the risk of dependence in young patients with chronic
symptoms. The main treatment of NSAID-induced gut
injury is discontinuance of the offending agent.
Smoking and IBD
Smoking has a deleterious effect on Crohn’s disease,
increasing the risk of flares, immunosuppressive drugs and
surgery. This risk is higher in females, especially those