What pharmacists should know and advise about ulcerative colitis and Crohn’s disease
Patients are increasingly presenting to pharmacies with symptoms of these gastrointestinal conditions, so what information and advice can pharmacists give?
Ulcerative colitis (UC) and Crohn’s disease are chronic gastrointestinal conditions that are considered the two main forms of inflammatory bowel disease (IBD). In the UK, these conditions affect half a million people, according to charity Crohn’s & Colitis UK.
When the symptoms are bad, it's called a flare-up or relapse. The periods between flare-ups, when symptoms are largely under control, are called remission. Flare-ups can last from a few days to several months.
- Diarrhoea: Frequent, urgent bowel movements that may include blood and mucus
- Abdominal cramps: May be severe, especially before a bowel movement
- Fatigue: Can be linked to anaemia, or be caused by disturbed sleep due to diarrhoea or cramps
- Feeling unwell: A raised temperature/fever
- Loss of appetite and/or weight: Caused by reduced absorption of nutrients
- Anaemia: Caused by blood loss or malabsorption of dietary iron, vitamin B-12 and folate, which are all essential for effective red blood cell function
- Mouth ulcers: Primarily a symptom of Crohn’s disease
In addition to the symptoms described above, there are a number of associated conditions:
- Joints: Inflammation of the joints (arthritis) can be a complication. The large joints, such as elbows, wrists, knees, and ankles are usually affected, but smaller joints and the spine/pelvis can also have issues. Symptoms improve with UC/Crohn’s treatment, with no lasting damage.
- Skin: Erythema nodosum causes red swellings that become bruise-like on the legs. The condition affects 1/20 and 1/7 people with UC and Crohn’s, respectively. Pyoderma gangrenosum, a condition that starts as small blisters that progress into painful ulcers and can appear anywhere, can be linked to flare-ups. Additionally, Sweet’s syndrome is associated with active Crohn’s disease. This condition causes tender red nodules on the arms, face and neck.
- Eyes: Swelling of the eyes due to episcleritis (inflammation of the outer coating of eye), scleritis (inflammation of the sclera - the white part of eye), and uveitis (inflammation of the iris). Scleritis and uveitis can lead to loss of vision if not treated appropriately.
- Bones: Due to inflammation, calcium absorption can be poor, causing osteoporosis and other bone loss conditions.
- Kidneys: Risk of kidney stone formation is high for those with UC and Crohn’s disease. Inflammation causes fat malabsorption, which binds to calcium and leaves a molecule called oxalate free to be absorbed and deposited in the kidneys. Dehydration, due to diarrhoea, can further contribute to kidney stone formation.
- Liver/gallbladder: Around one in three people with Crohn’s develop gallstones. A rare disease called Primary Sclerosing Cholangitis (PSC) can affect both people with Crohn’s and UC and can cause inflammation of the bile ducts and liver damage.
- Circulation: People with Crohn’s are over twice as likely to develop deep vein thrombosis (DVT) in the legs and pulmonary embolisms in the lungs. This is linked to immobility during times of flare-ups when patients are bed bound.
Recognising the difference between the two illnesses
As described above, the symptoms of UC and Crohn’s disease are similar and cannot easily be differentiated from one another. The major differences between the two conditions are:
- In UC, inflammation is limited to the colon, while Crohn’s disease affects the full gastrointestinal tract, from mouth to anus.
- In Crohn’s disease, the inflammation can ‘skip’ and leave normal areas between patches of diseased bowel.
- In UC, inflammation is focused on the inner lining of the colon, whereas, Crohn’s disease can occur in all layers of the bowel walls.
Managing conditions and recognising patient impact
Various diagnostic tests will be done, but neither UC or Crohn’s can be cured. Therefore, the aim of treatment is to control flare-ups and maintain remission. Treatment options are complex and dependent on the age of the patient, severity of symptoms and the extent (affected area) of disease. Full details can be found in the relevant NICE guidelines.
It’s important to remember that GI symptoms, such as diarrhoea, can considerably impact a person’s quality of life. It may limit the ability to leave the house or travel, which in turn affects their work and social life. It can also be a source of embarrassment and can lead to mental health issues such as anxiety and depression.
Furthermore, fatigue associated with anaemia can affect the person’s ability to function appropriately, which can also impact their daily lives.
Advice for patients
So, when speaking to a patient within a pharmacy setting, care should be taken to ensure that patient is comfortable. For example, a patient may be embarrassed when talking about GI symptoms. Therefore, speaking in a private setting, such as a consultation room, may be appropriate.
Ensure they have a good understanding of their disease and the pharmacological treatment they have been prescribed. Emphasise the importance of taking prescribed medication even when in remission. If suffering from diarrhoea, ensure they are drinking enough fluids.
Pharmacists can also recommend smoking cessation, stopping non-steroidal anti-inflammatory drugs (NSAIDs), and reducing stress, as these have been linked to flare-ups. Recommend keeping a diary to determine triggers.
Look out for the CPD module on ulcerative colitis and Crohn’s disease soon to be published on the C+D Community