Transcription:
Understanding Crohn's and Colitis - Part Two

Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and welcome to part two of our two part series on Crohn’s and Colitis Awareness. Joining me in this panel discussion is Dr. Dana Lukin. He’s the Clinical Director of Translational Research for the Jill Roberts Center for Inflammatory Bowel Disease at Weill Cornell Medical Center. And Dr. Randy Longman. He’s the Director of the Jill Roberts Center for Inflammatory Bowel Disease at Weill Cornell Medical Center. Dr. Lukin, as we head into part two, I couldn’t agree with you more about Dr. Longman’s excellent description of a very complicated topic and what an exciting time to be in your field. People have flare ups. As we’ve talked about some of these treatments and symptom management; patients tend to know their bodies. If they’ve had Crohn’s for a long time, they kind of know their triggers and their flare ups and sometimes self-medicate, take prednisone before they toddle off to the hospital. What do you want to tell them about doing that? And while you’re saying that does it ever become unmanageable to the point where a colostomy is considered and if it gets to that point, some people have felt that this is a cure and that they then do not have that inflammatory bowel disease anymore. So, speak about flare ups and self-medicating and then when it actually becomes that more definitive discussion.

Dr. Lukin:  Well thank you for several facets to this question. I think a little bit challenging to answer. I’m going to do my best to do this as thoroughly and concisely as I can. So, certainly inflammatory bowel diseases are chronic, and they’re generally characterized as waxing and waning. That’s more describing sort of the natural history or the untreated history is that it tends to ebb and flow over time. Now the goal of targeted disease modifying therapy is to minimize those ebbs and flows and keep patients maintained in remission, okay and when we talked about the treatment targets, so we obviously want clinical remission which is the absence of signs or symptoms of disease. But then we want to go a couple of notches further in this treat to target approach. 

So, rung number two besides clinical remission is actually steroid-free or corticosteroid-free remission. Okay, so that’s all of those things without relying upon steroids like prednisone as you mentioned. And so, as we move deeper into looking for endoscopic healing, number one the goal is to prevent disease activity, flares or exacerbations that are going to happen without maintenance therapy. So, in general, our hope is that treating the disease more effectively will minimize those. 

Now a lot of the societies including the Crohn’s and Colitis Foundation and the American Gastroenterological Association have really made it a priority that we emphasize the use of steroid-sparing therapies. So, the therapies, these biologic medications and immune modulators that Randy has just discussed in detail, really are meant to spare the use of chronic steroids. I say this every day that my patients know their bodies the best. They have been dealing with this oftentimes for many, many years. And obviously, know much more about the disease process as it impacts their bodies than the doctors that are treating the disease. But I think that it’s very important to try and not self-medicate especially with steroids because we know that there are a lot of adverse effects associated with chronic steroid use. And those are wide ranging including effects on the bones, and on blood sugar and on vision and skin and fractures and so, it’s really important that the patients don’t self-medicate. I certainly have my fair share of patients who really do understand that they have these intermittent obstructive episodes and will use steroids on their own for a few days and feel that it gets better. But I definitely encourage these patients to really have an open dialogue with their care team because that may be the sign that there’s something else that does need to be treated more proactively. 

Which brings us to the point of surgery. Now surgery in some circles might be thought of as a failure to respond to medical therapy and I think that this is definitely not the best way of thinking about it. There are many scenarios in which surgery is both medically indicated and may be the best course of action. These therapies that we’ve talked about which are fantastic and effective in many patients are only effective against active inflammation. In the event of Crohn’s Disease that has progressed over many years or maybe hasn’t been treated or recognized in an early enough time point, if there is scarring of the bowel; then often the therapies that we’re discussing aren’t going to reverse those symptoms, maybe nausea, abdominal distension, severe abdominal pain et cetera. And a surgical approach will be the best to remove the damaged bowel and then preserve the normal bowel afterwards and then you can reevaluate. 

So, the word cure is a very tricky terminology when it comes to inflammatory bowel disease which we believe unfortunately, we don’t have a cure at this point. I sort of liken it to a light in your house with a dimmer. We hope to get the lights so that you don’t see any light and but with a dimmer switch there’s a click that you need to turn the disease off and so the power is always on and so there’s a very high likelihood that the disease will return if we do stop the medication or even if we have surgery. Now you mentioned the term colostomy, not all surgery is a colostomy. And so, for ulcerative colitis, more commonly we would – if it came to surgery, we would be talking about a type of surgery that would remove the colon and often would then leave the ability to create a pouch type, an ileal pouch which can be replace the colon for bowel function thereafter. Now this is in some ways talked about as a cure but again, the inflammatory bowel disease, the genetics and all the switch – all those triggers that may have lead to it may still be there and so we have to be very – we have to follow our patients very carefully after that. 

For Crohn’s Disease, even if the surgery is effective in removing the active disease, we’re very cautious to say that this is not a cure and in fact, we often will use therapy after surgery because the likelihood of a relapse after that is much more common. And so unfortunately, there’s no magic bullet. It does emphasize that a multidisciplinary care team, gastroenterologists, colorectal surgeons, dietician nutritionist and often other specialists are very important for this care. So that was an answer to many sub questions in there so hopefully that is helpful. 

Host:  Well it certainly was and so now Dr. Longman, as we don’t have a lot of time left but this is such an important part of this discussion and if we ignored this part, we would be remiss. Tell us about diet, and this evolving role that you are both seeing in the treatment of inflammatory bowel diseases as far as foods that can help or hurt or how you work with your patients on diet plans so that some of those triggers, some of those little things that could really irritate the system are really looked out for. 

Dr. Longman:  I think this is a wonderful point and any person who suffers from inflammatory bowel disease knows that diet contributes to symptomatology. Now it is important to recognize that diet itself does not cause the inflammation. The inflammation is preexisting. However, there are modifications to the diet that can be helpful both during the inflammatory phase of the disease and then also during the quiescent phase. And as we do at the Jill Roberts Center, every patient meets with our IBD specific nutritionist because we feel that it is that important to make sure that we have the dietary intake to make sure that we understand sort of the dietary habits and to make sure that those are optimized. And for each person it may be – there may be some particulars with respect to fermentation or with respect to fiber dosing and so we frequently individualize these plans depending on the type of inflammatory bowel disease and the type of symptoms, but it clearly plays a central role. 

Dr. Lukin:  I was just going to add people – patients are frequently asked whether there are diets as therapy for inflammatory bowel disease and I think it’s a great topic and probably deserves its own podcast but unfortunately there’s no one IBD diet and it has to as Randy said, be individualized and I think that a lot of it also depends on what is the phenotype or the type of inflammatory bowel disease that a patient has. For example, a patient who has a lot of colon inflammation may find that a high fiber diet and roughage is going to be very irritating whereas a patient who has scarring from fibro stenotic Crohn’s Disease or stricture might not be able to tolerate foods that have a lot of residue and might get sort of stuck there. So, I think that you have to listen to your own body and very important to work with a dietician. People will often research a lot of diets that are on the internet and a lot of them have a lot of what looks like valid rationale for their use and look great but unfortunately there have been very few dietary studies that have been done rigorously to show that there’s a benefit and in fact, also not harm from doing some of these diets which can be very restrictive. So, I would say definitely if you are a patient and looking into diets as a possible compliment to medical therapy; then I think you should definitely talk to your physician as well as if a dietician is available to really personalize and understand why this might be right or might not be the right decision for you. 

Dr. Longman:  Can I just add that that is excellent Dr. Lukin and I would be remiss not to mention that the Jill Roberts Center is really playing a very active role in clinical research to try to understand this exact question. Dr. Lukin and myself are running studies to try to understand how diet can impact the underlying disease. Dr. Lukin is leading a study to understand how intermittent fasting or time restricted eating will impact Crohn’s Disease. We’re also studying how dietary supplements and fiber prebiotics can have an impact on fecal transplant for ulcerative colitis. So, the Jill Roberts Center at Cornell is really making a push to try to help understand how nutrition and diet can impact inflammatory bowel disease. 

Host:  Absolutely great points both of you. And I know that a lot of these patients look online as you say for various diets, and alternative therapies and we really could go on for a long time. It’s a great, great topic, but I’d like to give you each a chance to kind of give a last wrap up summary. So, Dr. Longman, I’d like to start with you. In this time of COVID, should patients with Crohn’s or colitis be concerned as they may be on immunosuppressive medication? What would you like them to know about what you’re doing at the Jill Roberts Center to keep them safe should they have to come in for their visits?

Dr. Longman:  Thanks that’s a really wonderful question and I think it’s one everyone’s mind these days with the COVID-19 pandemic. It’s a big concern, right and it’s totally understandable why anybody taking immunosuppressive therapy would be concerned in the face of the COVID-19 pandemic. Our own group led by myself and Dr. Lukin looked at the impact that COVID-19 had in patients with inflammatory bowel disease and one of the things that we found was that the best thing to do is to make sure that we keep your disease in check, make sure that you maintain your medicines even if they are immunosuppressive medicines because that’s really going to keep you the safest. If your disease flares, because you stopped taking your medicines, or if you need prednisone; those can be risk factors associated with coronavirus infections. And so, I think the most important thing is to speak with your doctor, particularly at the Jill Roberts Center, we’ve expanded our video visit capability and so the access is easy. Sign up online. Get a video visit with your provider, discuss these concerns. But in general, we find it very important to encourage patients to continue taking their medicines because that will really help them keep safe. 

Host:  Dr. Lukin, I’d like you to just reiterate this multidisciplinary approach to treating inflammatory bowel diseases, why it’s so important and your best advice please for people who have loved ones that are suffering from IBDs and what you would like them to know about what you can do for them at Weill Cornell Medical Center. 

Dr. Lukin:  Thank you for those last two questions. Inflammatory bowel disease is a multisystemic disease, right and so extraintestinal manifestations are very common. These can involve most commonly the joints but also the eyes with inflammatory conditions of the eyes, the skin and other systems. And so we frequently rely upon our colleagues as well as our experience to understand that when patients – first off listen to the patient and really take a good history and get to know our patients so that we can understand if something is new or changing and then we’re positioned to really refer our patients to our colleagues who are really part of our center, they are adjuncts of our center and able to make these referrals on a very timely manner and help patients to feel better. We also want to make sure that some of these extraintestinal symptoms may parallel disease activity and they may give us signs that a patient’s disease is less well under control than we initially thought. 

And so, at the Jill Roberts Center, we have very close relationships with our colorectal surgeons, our radiologists as well as dermatologists and ophthalmologists and we also work closely with our social workers and our nutritionists to make sure that we’re getting patients access to all the specialists that they would need. We also have close both clinical and research collaboration with rheumatology and the hospital for special surgery and so really making sure that those relationships are maintained. We have several conferences a month where we are interacting with our colorectal surgery team and our radiologists and our pathologists to make sure that our patients that have complex disease, we are putting our heads together and really thinking about the best course of action, referring to expert surgeons who are going to do the best job and give our patients the best chance to do well. 

Host: Wow gentlemen, thank you so much. What a amazing episode that was. So much information packed into this podcast. And it was such informative usable information for patients and for loved ones that have friends and family that have these IBD’s and thank you so much for joining us today. And while Weill Cornell Medicine continues to see patients in person as well as through video visits you can be confident of the safety of our appointments at Weill Cornell Medicine. And that concludes part two of our two part series on Crohn’s and Colitis Awareness, if you missed part one check that out as well. You don’t want to miss a minute of this fascinating and informative interview from back to health from Weill Cornell Medicine. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple podcasts, Spotify and Google Play Music. For more health tips please visit www.weillcornell.org and search podcasts. Parents, don’t forget to check out the Kid’s Healthcast. I’m Melanie Cole.