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Updates in Crohn's & Colitis Care
Dr. Alan Moss shares the symptoms of Crohn's & Colitis, and recent updates in the model of care for IBD.
Featured Speaker:
Alan Moss, MD
Dr. Moss is a nationally and internationally recognized expert in the treatment of Inflammatory Bowel Disease (IBD). He is a leading innovator in novel approaches to diagnosis and therapy, and serves on national committees for the American Gastroenterology Association and the Crohn’s & Colitis Foundation. Transcription:
Updates in Crohn's & Colitis Care
Melanie Cole, MS (Host): Welcome. In today’s show we’re giving updates in Crohn’s and colitis care. My guest is Dr. Alan Moss. He’s the medical director of the Crohn’s and colitis program at Boston Medical Center. Dr. Moss, it’s a pleasure to have you with us today. Tell us a little bit about the current state of Crohn’s and colitis and inflammatory bowel diseases. What are we seeing in the trends today?
Alan Moss MD, FACG, FEBG, AGAF, FRCPI (Guest): Thank you Melanie. So these diseases have really changed from in past years when it was mostly an in-patient management. Now most of the care for these patients has moved to the outpatient setting. We’re seeing increasing use of newer therapies, so called biologic therapies. We’re seeing far more coordinated care that involves addressing the holistic aspects of patients care and not just the disease or the symptoms, per se, for a given patient.
Host: That’s so interesting. As somebody who’s family has Crohn’s and colitis in it, tell us about that holistic model of care that you just mentioned and how it recognizes the complexity of these types of conditions.
Dr. Moss: Right. So if you think for most patients with Crohn’s and colitis, the typical time of life they develop these conditions are in their late teens, early 20s. Just around the time you’re starting college, starting working, starting a family. So if you develop a condition where you're having to go to the bathroom all the time, having lots of pain and diarrhea, it can really impact your quality of life. It can impact your work life, your study life. So it’s been recognized that we really need to address all of those in a care team. So we need to address the mental health of our patients, the social aspects of our patients, how they interact with others at work and at home and their family as well as dealing with the disease itself, controlling symptoms, and also ideally healing the inflammation in the intestinal track itself.
Host: Well so then tell us a little bit more about clinical care. What’s exciting in the field right now that you're seeing besides holistic care? We’ll get into the multidisciplinary need because there are so many different aspects to these conditions. What’s exciting in clinical care today doctor?
Dr. Moss: So the two main trends I think have been A, we have a lot of new drugs available to treat patients with. So when I started in this field 10/15 years, we had two really good drugs. Now we have six or eight good drugs and more in the pipeline. But that’s exciting because it means we have far more options on the table to help patients control the disease. The second trend has been that we are now really focusing not just on improving symptoms, not just on healing the colon on the macroscopic level, but also healing the colon at the microscopic level. So we’ve really shifted our targets to aim for full healing of the disease as a goal rather than just trying to help the patient feel better alone. Those are the two main trends and they have really made us, if you like, more focused on aiming for those with the drugs we use rather than just helping people feel better but not really paying attention to what’s going on at the organ level.
Host: One of the fascinating things I find about inflammatory bowel disease is the evolving role of diet in the pathogenesis and the treatment of these conditions. Tell us about diet and what you're counselling your patients on as far as diets to adhere to and specific things you want them to look at. That can even include probiotics or prebiotics or any of the things they're hearing about in the media today.
Dr. Moss: It’s interesting Melanie because that’s probably the most common question patients have and it’s probably the most under researched area I would say in terms of cause and effect for Crohn’s and colitis and also treatment. I will tell you we do know that there are certain diets that make you more likely to develop these conditions if you have a susceptibility. For example, the classical diet that’s high in processed foods, high in saturated fats, high in carbohydrates or simple sugars does make you at greater risk if you're at risk of developing Crohn’s disease because of other factors. But then once you have Crohn’s or colitis, again, each patient has different factors. For some patient, they may because lactose or fructose intolerant in addition to their Crohn’s or colitis. There’s a lot of research now on diets that try and shift away from simple sugars to more complex sugars to try and help disease symptoms.
Then the other extreme is diets where you try and exclude many factors that trigger your symptoms one by one and the reintroduce them and try and see which ones for you are your triggers. I will say overall diet is far more individualized that just prescribing a drug, and it requires a little bit more work both in the patient and the team to figure out in an individual case what factors are triggering their symptoms per se.
Host: Well then let’s talk about the team because these conditions require so many as you said in your first answer about the different people that are involved. It could be mental health and it certainly is involving medicational intervention. Tell us about your multidisciplinary team that could involve the social worker, a care coordinator, even a clinical pharmacist on staff.
Dr. Moss: Right. So this model evolved from other conditions and has been really pioneered at the University of Pittsburgh and more recently Carolina Tech and what they call the medical home. So at the center is the patients, and then at various different meetings or visits you may have them meet a clinical pharmacist or the pharmacy team. Their goals is to make sure all your PAs are sorted out. You’ve got the right medication at the right time. You may meet a medical social worker who will help with counselling and stress management and coping with various issues. You also meet the nurses who are really helpful in triaging acute issues and dealing with the day to day issues that arise. A nutritionist who may help with, as you mentioned, diet. Try to identify for each patient their food triggers and help them make good food choices. Then the coordinators. So for many patients there’s so many things happening between x-rays and blood tests and pharmacy and so forth that having one person who we describe it as like an air traffic controller. They're coordinating all your care is key just to help them manage all the complexities of the disease in addition to the typical people you think of like the MDs or the PAs that you might see in the clinic.
Host: Another thing that I find interesting that people are talking about is CBD oil to help with Crohn’s symptoms. A lot of this is about symptom management. Maybe it doesn’t affect the inflammatory markers or the disease process itself but symptoms. Are you getting this question, doctor, and what do you say about it?
Dr. Moss: Absolutely. You know CBD or marijuana is approved for medical purposes in Massachusetts. So for many years people have come to us asking about it. My kind of overview of the research would suggest that it can certainly be beneficial in treating pain as one of the main symptoms of Crohn’s disease. The data does not suggest right now that it’s treating the actual inflammation at the tissue level, but there are certainly scenarios where people may be optimized on medical therapy. Their disease is partially controlled but they're still having issues with pain. Sometimes that’s the right scenario for these kinds of interventions. But certainly there's no studies yet saying that CBD per se is going to treat the underlying inflammation and that remains uncertain.
Host: Well thank you for that answer. What do we know about lifestyle for treatment and triggers? When you're speaking to your patients about stress modification and exercise, and we’ve talked a little bit about diet, what do you tell them about things that they can do in their lifestyle that can possibly help to identify these triggers or to hopefully tamp down some of those symptoms.
Dr. Moss: I think this is something that we as physicians have underappreciated for a long time. I would say that most patients with Crohn’s or colitis, I ask them myself, “Look, what do you find are the triggers?” Most patients know their bodies very well. A lot of research recently has focused on sleep. Studies showing that poor sleep patterns are being associated with worsening of disease activity. Also it’s very important patients with Crohn’s or colitis get adequate levels of exercise. Unfortunately, some of the medicines we use like steroids make patients gain weight, and that can be hard to shift after they're off their steroids. So having a good healthy exercise regiment is key. Having adequate sleep is key. Managing stress is very important. You know in certain scenarios you can't remove the trigger, but you can give patients tools to cope with the stress better. Then in that way allow them to deal with it better in their daily life. So I think all three are definitely important. We did a poor job in the past of appreciating them, but now we’re recognizing their importance in, again, this overall holistic approach to patient care.
Host: What great information as we’re updating colitis and Crohn’s. Dr. Moss, give us your best advice. Wrap it up for us with a summary on what you find exciting in this field and what you want patients to know about the care that they can receive at Boston Medical Center.
Dr. Moss: I think the main exciting thing in the field now is the role of the microbiome and your intestinal bacteria. Not just how the disease develops, but also maintaining disease. For patient management I think it’s key to find a place where you’ve got all those parts are present for you. You have access to social work, to pharmacists, to nurses, MDs, PAs, nutritionists. All that is part of an important picture rather than just the prescription per se. So we are glad to be able to develop a program with those here at Boston Medical Center and hope that will be beneficial to our patients.
Host: Well, I am certain that it will. Thank you so much Dr. Moss for coming on today. It was a great segment. Thank you for sharing your expertise. That wraps up this episode of Boston Medtalks with Boston Medical Center. Please visit our website at bmc.org for more information on inflammatory bowel diseases and to get connected with one of our providers. If you found this podcast as educational and informative as I did, please share with people that you know that may have Crohn’s or colitis. Please share on your social channels and be sure not to miss all the other interesting podcasts in the Boston Medical Center library. I'm Melanie Cole. Thanks so much for listening.
Updates in Crohn's & Colitis Care
Melanie Cole, MS (Host): Welcome. In today’s show we’re giving updates in Crohn’s and colitis care. My guest is Dr. Alan Moss. He’s the medical director of the Crohn’s and colitis program at Boston Medical Center. Dr. Moss, it’s a pleasure to have you with us today. Tell us a little bit about the current state of Crohn’s and colitis and inflammatory bowel diseases. What are we seeing in the trends today?
Alan Moss MD, FACG, FEBG, AGAF, FRCPI (Guest): Thank you Melanie. So these diseases have really changed from in past years when it was mostly an in-patient management. Now most of the care for these patients has moved to the outpatient setting. We’re seeing increasing use of newer therapies, so called biologic therapies. We’re seeing far more coordinated care that involves addressing the holistic aspects of patients care and not just the disease or the symptoms, per se, for a given patient.
Host: That’s so interesting. As somebody who’s family has Crohn’s and colitis in it, tell us about that holistic model of care that you just mentioned and how it recognizes the complexity of these types of conditions.
Dr. Moss: Right. So if you think for most patients with Crohn’s and colitis, the typical time of life they develop these conditions are in their late teens, early 20s. Just around the time you’re starting college, starting working, starting a family. So if you develop a condition where you're having to go to the bathroom all the time, having lots of pain and diarrhea, it can really impact your quality of life. It can impact your work life, your study life. So it’s been recognized that we really need to address all of those in a care team. So we need to address the mental health of our patients, the social aspects of our patients, how they interact with others at work and at home and their family as well as dealing with the disease itself, controlling symptoms, and also ideally healing the inflammation in the intestinal track itself.
Host: Well so then tell us a little bit more about clinical care. What’s exciting in the field right now that you're seeing besides holistic care? We’ll get into the multidisciplinary need because there are so many different aspects to these conditions. What’s exciting in clinical care today doctor?
Dr. Moss: So the two main trends I think have been A, we have a lot of new drugs available to treat patients with. So when I started in this field 10/15 years, we had two really good drugs. Now we have six or eight good drugs and more in the pipeline. But that’s exciting because it means we have far more options on the table to help patients control the disease. The second trend has been that we are now really focusing not just on improving symptoms, not just on healing the colon on the macroscopic level, but also healing the colon at the microscopic level. So we’ve really shifted our targets to aim for full healing of the disease as a goal rather than just trying to help the patient feel better alone. Those are the two main trends and they have really made us, if you like, more focused on aiming for those with the drugs we use rather than just helping people feel better but not really paying attention to what’s going on at the organ level.
Host: One of the fascinating things I find about inflammatory bowel disease is the evolving role of diet in the pathogenesis and the treatment of these conditions. Tell us about diet and what you're counselling your patients on as far as diets to adhere to and specific things you want them to look at. That can even include probiotics or prebiotics or any of the things they're hearing about in the media today.
Dr. Moss: It’s interesting Melanie because that’s probably the most common question patients have and it’s probably the most under researched area I would say in terms of cause and effect for Crohn’s and colitis and also treatment. I will tell you we do know that there are certain diets that make you more likely to develop these conditions if you have a susceptibility. For example, the classical diet that’s high in processed foods, high in saturated fats, high in carbohydrates or simple sugars does make you at greater risk if you're at risk of developing Crohn’s disease because of other factors. But then once you have Crohn’s or colitis, again, each patient has different factors. For some patient, they may because lactose or fructose intolerant in addition to their Crohn’s or colitis. There’s a lot of research now on diets that try and shift away from simple sugars to more complex sugars to try and help disease symptoms.
Then the other extreme is diets where you try and exclude many factors that trigger your symptoms one by one and the reintroduce them and try and see which ones for you are your triggers. I will say overall diet is far more individualized that just prescribing a drug, and it requires a little bit more work both in the patient and the team to figure out in an individual case what factors are triggering their symptoms per se.
Host: Well then let’s talk about the team because these conditions require so many as you said in your first answer about the different people that are involved. It could be mental health and it certainly is involving medicational intervention. Tell us about your multidisciplinary team that could involve the social worker, a care coordinator, even a clinical pharmacist on staff.
Dr. Moss: Right. So this model evolved from other conditions and has been really pioneered at the University of Pittsburgh and more recently Carolina Tech and what they call the medical home. So at the center is the patients, and then at various different meetings or visits you may have them meet a clinical pharmacist or the pharmacy team. Their goals is to make sure all your PAs are sorted out. You’ve got the right medication at the right time. You may meet a medical social worker who will help with counselling and stress management and coping with various issues. You also meet the nurses who are really helpful in triaging acute issues and dealing with the day to day issues that arise. A nutritionist who may help with, as you mentioned, diet. Try to identify for each patient their food triggers and help them make good food choices. Then the coordinators. So for many patients there’s so many things happening between x-rays and blood tests and pharmacy and so forth that having one person who we describe it as like an air traffic controller. They're coordinating all your care is key just to help them manage all the complexities of the disease in addition to the typical people you think of like the MDs or the PAs that you might see in the clinic.
Host: Another thing that I find interesting that people are talking about is CBD oil to help with Crohn’s symptoms. A lot of this is about symptom management. Maybe it doesn’t affect the inflammatory markers or the disease process itself but symptoms. Are you getting this question, doctor, and what do you say about it?
Dr. Moss: Absolutely. You know CBD or marijuana is approved for medical purposes in Massachusetts. So for many years people have come to us asking about it. My kind of overview of the research would suggest that it can certainly be beneficial in treating pain as one of the main symptoms of Crohn’s disease. The data does not suggest right now that it’s treating the actual inflammation at the tissue level, but there are certainly scenarios where people may be optimized on medical therapy. Their disease is partially controlled but they're still having issues with pain. Sometimes that’s the right scenario for these kinds of interventions. But certainly there's no studies yet saying that CBD per se is going to treat the underlying inflammation and that remains uncertain.
Host: Well thank you for that answer. What do we know about lifestyle for treatment and triggers? When you're speaking to your patients about stress modification and exercise, and we’ve talked a little bit about diet, what do you tell them about things that they can do in their lifestyle that can possibly help to identify these triggers or to hopefully tamp down some of those symptoms.
Dr. Moss: I think this is something that we as physicians have underappreciated for a long time. I would say that most patients with Crohn’s or colitis, I ask them myself, “Look, what do you find are the triggers?” Most patients know their bodies very well. A lot of research recently has focused on sleep. Studies showing that poor sleep patterns are being associated with worsening of disease activity. Also it’s very important patients with Crohn’s or colitis get adequate levels of exercise. Unfortunately, some of the medicines we use like steroids make patients gain weight, and that can be hard to shift after they're off their steroids. So having a good healthy exercise regiment is key. Having adequate sleep is key. Managing stress is very important. You know in certain scenarios you can't remove the trigger, but you can give patients tools to cope with the stress better. Then in that way allow them to deal with it better in their daily life. So I think all three are definitely important. We did a poor job in the past of appreciating them, but now we’re recognizing their importance in, again, this overall holistic approach to patient care.
Host: What great information as we’re updating colitis and Crohn’s. Dr. Moss, give us your best advice. Wrap it up for us with a summary on what you find exciting in this field and what you want patients to know about the care that they can receive at Boston Medical Center.
Dr. Moss: I think the main exciting thing in the field now is the role of the microbiome and your intestinal bacteria. Not just how the disease develops, but also maintaining disease. For patient management I think it’s key to find a place where you’ve got all those parts are present for you. You have access to social work, to pharmacists, to nurses, MDs, PAs, nutritionists. All that is part of an important picture rather than just the prescription per se. So we are glad to be able to develop a program with those here at Boston Medical Center and hope that will be beneficial to our patients.
Host: Well, I am certain that it will. Thank you so much Dr. Moss for coming on today. It was a great segment. Thank you for sharing your expertise. That wraps up this episode of Boston Medtalks with Boston Medical Center. Please visit our website at bmc.org for more information on inflammatory bowel diseases and to get connected with one of our providers. If you found this podcast as educational and informative as I did, please share with people that you know that may have Crohn’s or colitis. Please share on your social channels and be sure not to miss all the other interesting podcasts in the Boston Medical Center library. I'm Melanie Cole. Thanks so much for listening.