Tags: IBD
Inflammatory bowel disease (IBD) is at least two, separate disorders that cause inflammation (redness and swelling) and ulceration (sores) of the small and large intestines. These two disorders are called ulcerative colitis and Crohn's disease.
Crohn's disease can occur anywhere in the digestive tract but is common in the lower small bowel (ileum) or large bowel.
Malnutrition and blood disorders are common conditions in Crohn's Disease patients found to be caused by avoiding food items either because of existing symptoms or concern that they may bring on symptoms. Almost half of Crohn's Disease patients have additional health issues affecting their joints, skin, eyes, and biliary tract that may be more debilitating than the bowel symptoms.
Canada has one of the highest incidence and prevalence rates of IBD in the world with more than 200,000 Canadians living with the disease. These disorders are expensive and can be debilitating. The total direct and indirect costs of IBD are $1.8 billion with the main indirect cost being related to long-term work loss. The average age for people developing IBD often coincides with the most important socioeconomic period of life. The severity of symptoms may prevent those with IBD from realizing their career potential or family creation.
The New Brunswick Department of Health has launched a Biosimilars Initiative which involves switching patients from originator biologic drugs to their biosimilar versions. It follows the successful implementations of similar initiatives by British Columbia and Alberta. In addition, switching to biosimilars has been conducted extensively in Europe, where countries have had over 15 years of experience with biosimilars.
As of April 21, 2021, New Brunswick's Provincial Drug Plan will only cover the use of the following biosimilars, used to treat Crohn’s disease and ulcerative colitis:
Those who wish to continue their coverage will be required to switch to avoid any disruption.
If you are currently receiving Remicade® or Humira® to treat your Crohn’s disease or ulcerative colitis and you depend on New Brunswick Drug Plans you may require a new prescription to continue coverage and should contact your health care professional to discuss this policy change before November 30th, 2021.
During this period, both the originator biologic and its biosimilar versions will be covered to allow prescribers and patients time to discuss treatment options and to switch patients to a biosimilar.
Medically necessary exemptions will be considered on a case-by-case basis. Your healthcare professional will determine whether to request an exemption for you.
A biosimilar is a drug proven to be highly similar to a biologic drug that has been authorized for sale in Canada (known as the reference biologic drug). Biosimilars have been approved by Health Canada based on a thorough comparison to a reference biologic drug and may enter the market after the reference biologic drugs’ patents and data protection has expired.
Biosimilar products first entered the Canadian market in 2009. Health Canada has already approved over 30 biosimilars, including some that are used to treat IBD (Crohn’s disease and ulcerative colitis): Inflectra (infliximab), Renflexis (infliximab), Avsola (infliximab), Hadlima (adalimumab), Idacio (adalimumab), Hyrimoz (adalimumab), Amgetiva (adalimumab) and Hulio (adalimumab).
To be approved in Canada, a biosimilar must be proven to have no clinically meaningful differences to the reference biologic. This means, studies of the biosimilar MUST show that there are no differences in outcomes for patients taking a biosimilar, compared to those taking a reference biologic drug. Rigorous standards for authorization by Health Canada mean that patients and health care providers can have the same confidence in the quality, safety and efficacy of a biosimilar.
Health Canada supports switching from a biologic to a biosimilar and considers that a one-time switch from a reference biologic drug to a biosimilar to be acceptable. Health Canada also recommends that the decision to switch be made by the physician/prescriber and patient, taking into account any policies of the relevant jurisdiction.
Biologic (reference) drugs are medications made by using living organisms (such as yeast or animal cells) to produce complex proteins that are purified then administered to affect certain processes in the human body.
A biosimilar is a drug demonstrated to be highly similar to a biologic (reference) drug, that has been authorized for sale in Canada.
Health Canada is responsible for ensuring the safety, efficacy, and quality of all new drugs including biologics and biosimilars. For a biosimilar drug to be approved in Canada, Health Canada must find no meaningful differences in safety and effectiveness compared to the biologic.
"The government's initiative to increase the use of biosimilars makes sense, as the resulting savings have been guaranteed to stay in the public drug plans to fund new drugs. Biosimilars are just as safe and effective as the originator versions, as demonstrated by the experiences in British Columbia, Alberta and Europe." - Dr. Mark MacMillan, Gastroenterologist and Assistant Professor in Division of Digestive Care & Endoscopy at Dalhousie University Department of Medicine
See more here.
As part of the biosimilars initiative, if you receive coverage through a New Brunswick Drug Plan and you currently take Remicade® or Humira® for the treatment of Crohn’s disease or ulcerative colitis, you must switch to the biosimilar version before the end of the transition period (November 30, 2021) to avoid any disruption to your coverage. There may be medical reasons why you cannot switch to a biosimilar. Your healthcare provider can help you determine if it is medically necessary to remain on a biologic (reference) drug and will confirm if you qualify for an exemption.
The New Brunswick Biosimilars Initiative is a result of the New Brunswick Drug Plans’ evidence-informed strategy to better optimize our public resources, get the best value for new treatments and services, and improve access to medications for patients. Increasing the uptake of other biosimilars will provide savings that will be used to cover new drugs and contribute to the sustainability of the public drug plans.
Originator biologic drugs make up some of New Brunswick Drug Plans’ largest drug expenditures, and their costs are growing at an unsustainable rate. In 2019-20, New Brunswick Drug Plans’ spending on biologic drugs grew by 19% to $63.8 million. In the same year, biologic drugs accounted for 29.4% of drug costs but only represented 1.5% of the total number of claims.
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Crohn's is a chronic (long-term) condition with symptoms that can disappear and then flare up again throughout your life. Living with the unpredictable nature of Crohn's can pose physical and emotional challenges that may seem overwhelming at times. However, there are several things that you can do to contribute to your health and well-being.
Be informed, proactive, and involved in your care. By establishing a solid partnership with your health care team, developing coping skills, and maintaining a positive outlook, it is possible to stay healthy and happy, despite living with Crohn's disease.
Although diet and stress do not cause ulcerative colitis, there may be times when changes in your lifestyle may help control your symptoms and lengthen the time between flare-ups. The following changes may help to ease your symptoms:
Ask your doctor or pharmacist if one of these formulations may be right for you. It is important to take the probiotic in the dose and duration recommended by the manufacturer to achieve the best results.
Many of the symptoms of Crohn's Disease are similar. Symptoms outside the gut may include aching, sore joints, skin and mouth sores and red, inflamed eyes.
The most common symptoms of Crohn's disease are abdominal pain (often in the right, lower area of the abdomen) and diarrhea. There may also be rectal bleeding, weight loss and fever. Children may suffer poor growth.
Too many people skip potentially life-saving procedures because of misunderstandings and misconceptions about the bowel prep. However, most people who have had colonoscopies, will tell you it isn't nearly as bad as you think and that the benefits far outweigh the risks.
Although several drugs are useful in controlling these conditions, as yet a cure has not been found. Since the disease is not curable, long-term treatment is often required.
These include anti-inflammatory drugs (sulfasalazine/5-ASA), corticosteroids (prednisone and budesonide),immunosuppressives (methotrexate and azathioprine) and immunomodulatory agents (infliximab). Some of these may be given by different methods including oral, rectal and intravenously. Antibiotics may be useful in certain circumstances for Crohn's disease.
Click through our online e-learning tool below to explore the different medications and treatment options for IBD. Remember, no treatment is NOT an option!
Specific medications are used to treat diarrhea and abdominal cramps. Anti-diarrheal drugs slow the muscles of the intestine which in turn slow the passage of stool through the body and help with diarrhea. While abdominal pain often occurs with IBD, it is important to note that the pain is a consequence of the disease and, if treated appropriately, the pain should subside. People with IBD should be careful to avoid taking an excess of pain killers and anti-diarrheal drugs since this may lead to complications.
Diet alone is not effective in treating Crohn's disease or ulcerative colitis. However, it is important that patients with IBD have a well-balanced diet. Calcium is important to protect bones. Fibre may not be tolerated during flare ups. Certain vitamins (for example, B12) may be required. Selected patients may sometimes be helped by a registered dietitian.
Click here for more information on diet and lifestyle for IBD.
People with both Crohn's disease and ulcerative colitis may need surgery at some point in their lives. Surgery is less common in ulcerative colitis than in Crohn's disease and is often performed when ulcerative colitis is no longer responding to medical treatment. Unlike Crohn's disease, surgery will cure ulcerative colitis by removing all diseased bowel. With the colon being completely removed the patient may require an ileostomy (bag outside the body to collect waste) or a second operation to form a new rectum (called a pouch procedure). Despite all of the advances in medical research over the last several decades, we still do not know the cause of IBD and much further research is required.
Tests are needed to determine whether the patient has ulcerative colitis or Crohn's disease and to rule out other causes. To diagnose these disorders the doctor will take a complete history and perform a physical examination. In addition, blood tests are used to find out if you are anemic (low blood count) as a result of blood loss, or if there is an increased number of white blood cells in your body, suggesting an inflammatory process
Stool samples can tell your doctor if there is blood loss or if an infection by a parasite or bacteria is causing some of your symptoms.
The doctor may also look inside your rectum and large bowel through a long, flexible video camera called an endoscope. During this safe procedure, samples of the lining of the intestine (biopsies) may be taken to be looked at under the microscope.
On some occasions an X-ray exam may be required. This is done by putting barium (a white chalky solution) into the upper intestine (swallowing barium) or by putting the barium into the bowel by inserting a tube into the anus
Citations:
Crohn’s and Colitis Foundation of Canada. 2012. The impact of inflammatory bowel disease in Canada - 2012 Final report and recommendations.http://crohnsandcolitis.ca/Crohns_and_Colitis/documents/reports/ccfc-ibd-impact-report-2012.pdf?ext=.pdf [accessed 3 September 2018]
Fedorak RN et al. Canadian Digestive Health Foundation Public Impact Series 4: Inflammatory bowel disease in Canada. Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol. 2010 Nov;24(11):651-5.
Ng SC et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: A systematic review of population-based studies. Lancet. 2018 Dec 23;390(10114):2769-78.
People with Crohn's Disease are at an increased risk of developing colon cancer. Having regular endoscopies will help identify polyps that could potentially develop into cancer.
Diet alone is not effective in treating Crohn's disease. However, it is important that patients with Crohn's Disease have a well-balanced diet. Calcium is important to protect bones. Fibre may not be tolerated during flare ups. Certain vitamins (for example, B12) may be required. Selected patients may sometimes be helped by a registered dietitian.
Although both illnesses can be seriously debilitating, there are several primary differences between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). IBD is an autoimmune disorder that causes swelling and ulcerations (sores) in the bowel. IBS involves problems with motility (how the bowel moves contents through our intestines) and sensitivity (how the brain interprets sensations in the bowel). Symptoms of IBS may wax and wane and possibly disappear altogether whereas IBD is a chronic condition.
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Making informed decisions is imperative to your good health but understanding the benefits and risks associated with IBD therapy options can be challenging. CDHF developed the IBD e-BRAT – a tool to help you learn more about common risks as well as important benefits around the therapy options. Explore your options on the tool now!
This e-learning tool was made possible due to an unrestricted educational grant from Pfizer Canada
On May 18, 2021 the Minister of Health and Social Services, Christian Dubé, announced that the Quebec government is initiating a biosimilars Initiative which involves switching patients from originator biologic drugs to their biosimilar versions. It follows the successful implementations of similar initiatives by British Columbia and Alberta. In addition, switching to biosimilars has been conducted extensively in Europe, where countries have had over 15 years of experience with biosimilars.
As of April 12, 2022, Quebec's Health Insurance Plan (RAMQ) will only cover the use of the following biosimilars, used to treat Crohn’s disease and ulcerative colitis:
Those who wish to continue their coverage will be required to switch to avoid any disruption.
If you are currently receiving Remicade® or Humira® to treat your Crohn’s disease or ulcerative colitis and you depend on Quebec's Health Insurance Plan (RAMQ) you may require a new prescription to continue coverage and should contact your health care professional to discuss this policy change before April 12, 2022.
Medically necessary exemptions will be considered on a case-by-case basis. Your healthcare professional will determine whether to request an exemption for you.
A biosimilar is a drug proven to be highly similar to a biologic drug that has been authorized for sale in Canada (known as the reference biologic drug). Biosimilars have been approved by Health Canada based on a thorough comparison to a reference biologic drug and may enter the market after the reference biologic drugs’ patents and data protection has expired.
Biosimilar products first entered the Canadian market in 2009. Health Canada has already approved over 30 biosimilars, including some that are used to treat IBD (Crohn’s disease and ulcerative colitis): Inflectra (infliximab), Renflexis (infliximab), Avsola (infliximab), Hadlima (adalimumab), Idacio (adalimumab), Hyrimoz (adalimumab), Amgetiva (adalimumab) and Hulio (adalimumab).
To be approved in Canada, a biosimilar must be proven to have no clinically meaningful differences to the reference biologic. This means, studies of the biosimilar MUST show that there are no differences in outcomes for patients taking a biosimilar, compared to those taking a reference biologic drug. Rigorous standards for authorization by Health Canada mean that patients and health care providers can have the same confidence in the quality, safety and efficacy of a biosimilar.
Health Canada supports switching from a biologic to a biosimilar and considers that a one-time switch from a reference biologic drug to a biosimilar to be acceptable. Health Canada also recommends that the decision to switch be made by the physician/prescriber and patient, taking into account any policies of the relevant jurisdiction.
Biologic (reference) drugs are medications made by using living organisms (such as yeast or animal cells) to produce complex proteins that are purified then administered to affect certain processes in the human body.
A biosimilar is a drug demonstrated to be highly similar to a biologic (reference) drug, that has been authorized for sale in Canada.
Health Canada is responsible for ensuring the safety, efficacy, and quality of all new drugs including biologics and biosimilars. For a biosimilar drug to be approved in Canada, Health Canada must find no meaningful differences in safety and effectiveness compared to the biologic.
"The government's initiative to increase the use of biosimilars makes sense, as the resulting savings have been guaranteed to stay in the public drug plans to fund new drugs. Biosimilars are just as safe and effective as the originator versions, as demonstrated by the experiences in British Columbia, Alberta and Europe." - Dr. Mark MacMillan, Gastroenterologist and Assistant Professor in Division of Digestive Care & Endoscopy at Dalhousie University Department of Medicine
See more here.
As part of the biosimilars initiative, if you receive coverarage in Quebec and you currently take Remicade® or Humira® for the treatment of Crohn’s disease or ulcerative colitis, you must switch to the biosimilar version before the end of the transition period (April 12, 2022) to avoid any disruption to your coverage. There may be medical reasons why you cannot switch to a biosimilar. Your healthcare provider can help you determine if it is medically necessary to remain on a biologic (reference) drug and will confirm if you qualify for an exemption.
The Minister of Health and Social Services, Christian Dubé, announces that the Quebec government is initiating a shift in favor of the use of biosimilar drugs, which will generate annual savings of more than $ 100 million, only for the public health plan. drug insurance and its insureds. These savings will be reinvested in the health system, in particular to improve access to innovative drug therapies.
Despite the inclusion of several biosimilar drugs on the drug lists for many years following recommendations issued by the National Institute of Excellence in Health and Social Services (INESSS), they remain underused. This situation generates a considerable additional cost for the General Prescription Drug Insurance Plan since biosimilar drugs are significantly less expensive than reference drugs, with no difference in therapy for patients.
"Innovation is giving rise to incredible medical advances and to the development of healthcare practices and offers that are always better suited to people's needs. The decisive shift we are taking towards the judicious use of biosimilar drugs is a good example of this. I am convinced that this will help ensure the sustainability and viability of our health system. We have the health of the population at heart and the actions taken in this matter are in the interest and for the benefit of patients." - Christian Dubé, Minister of Health and Social Services
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Date Written: 09-2020
*This information is intended for educational purposes and is not intended to replace recommendations that have been provided by your Physician and Health Care Team.
Healthy eating objectives for IBD include managing symptoms, ensuring and optimizing adequate intake, promoting healing, reducing complications and meeting other relevant personal needs.
There is no miracle cure for Crohn’s and ulcerative colitis, through a special diet, food combinations, or exclusions of select foods or nutrients. Individuals with IBD, including Crohn’s disease and ulcerative colitis may feel well, or ill during a flare-up, leading to variations in appetite and nutritional intake depending on the state of their IBD.
During a flare-up and even when feeling well, it is important to be well-nourished to support healing, build strength, reduce inflammation and optimize nutritional intake. If you feel ill during a flare-up, making effective changes to diet may potentially help you to manage symptoms.
You may find some improvements or worsening in your symptoms based on certain foods. Keep a diary, it is worth tracking food intake to try and determine possible symptom triggers. However, it is important to assess whether other factors like stress, hormones, level of sleep and physical activity contribute to worsening of symptoms rather than merely foods as the cause.
Take the time to track your symptoms in the CDHF app that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.
Canada’s Food Guide is a tool that can be used to guide your meal and snack choices. Consuming a variety of vegetables and fruits, whole grains, lean meat and protein choices provides a range of vitamins and minerals that you need daily.
Aim to fill half the plate with a variety of vegetables and fruit, fill one-quarter of the plate with healthy whole grains like bread, unsweetened cereals, pasta, rice and quinoa. Fill the remaining quarter of the plate with protein, including lean meat, poultry, fish, eggs, soy, dairy and non-dairy fortified milk, yogurt and cheese.
If your appetite is low, consume small frequent meals and snacks to consume adequate intake and prevent malnutrition.
Consume adequate amounts of fluid intake to move wastes through your system and prevent dehydration.
If your diet intake is inadequate due to poor appetite, reduced intake, or malabsorption and difficulty meeting nutritional needs, discuss strategies with your Physician and Registered Dietitian. Consuming small frequent meals and snacks, high-calorie foods, or supplements like Ensure or Boost may be beneficial.
Daily fibre intake and goals should be discussed with your Physician, especially for those with Crohn’s disease with strictures and at risk of a bowel obstruction.
Dietitian’s of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020, does not recommend a high fibre nor a low fibre diet to help manage Crohn’s disease, either active or in remission, so it is best to maintain normal fibre intake.
Health Canada recommends Canadian women consume 25 grams of fibre/day and men consume 38 grams of fibre/day, though most Canadians are consuming about half that requirement.
Some people find fibre to improve their symptoms of constipation, yet others find fibre tends to irritate their symptoms during a flare. If you have concerns or questions about your fibre intake, consult your Physician or Registered Dietitian.
During a flare-up, protein needs are higher. Increase protein intake at meals, and with snacks, including meat, fish, poultry, soy and soy products like tofu, dairy and fortified non-dairy milk, yogurt and cheese, plain nuts and seeds and nut and seed butters.
Typical portion servings are about the size of a regular deck of playing cards, 2 tablespoons of nut butter, ¼ cup of plain nuts or 2 eggs.
Adults should consume 2-3 tablespoons of healthy fats in cooking and in foods throughout the day. Unsaturated fats like olive oil, avocado oil, omega-3 found in fatty fish like salmon, sardines, trout as well as plain nuts are all healthy choices.
Some common nutrients of concern for adults with IBD, and select food sources containing the nutrients:
Source: Dietitians of Canada. 2019. PEN. Inflammatory Bowel Disease in Adults.
Certain medications (methotrexate and sulphasalazine) can increase the need for folic acid supplements.
Some individuals have increased nutrients needs, including calcium, iron, and vitamin D. Discuss your specific needs, including potential benefits of vitamin supplements with your Physician or Registered Dietitian. Regular screening for iron deficiency anemia may be advised.
You could temporarily remove one food from your diet at a time to see if your gas symptoms improve.
If you find some dairy products cause gas and bloating, it could be due to lactose. Some people, particularly during a flare-up, may become intolerant to lactose, the sugar in dairy products. A lactose-free diet may help to alleviate symptoms. Look for lactose on food labels and buy lactose-free dairy products. The lactose intolerance may be temporary. Some of the symptoms of lactose-intolerance are like a flare-up, so before altering your diet, discuss your symptoms with your Physician.
Unless you have symptoms to specific foods, do not remove them from your diet. Everyone is different, and what causes issues for one person may not have the same reaction for others. If you remove foods from the diet, make sure to check your tolerance to these foods from time to time, as symptoms can vary over time. Also, restricting foods can lead to extensive lists of foods excluded from the diet, which can increase the risk of nutrient deficiencies.
If a low FODMAP diet is advised by your Physician, consult with a Registered Dietitian who has expertise with the diet. This diet is meant to only be temporary for just a few weeks, then foods are added back into the diet systematically to expand nutritional intake. Following the low FODMAP diet for longer than a few weeks can have negative effects on the body. The FODMAPs are food for the microbes that reside in your intestine and provide health benefits. Staying on this diet can have negative effects on your microbiome (microbes). The low FODMAP diet may be effective in helping you, and your Registered Dietitian determine what foods potentially trigger your symptoms.
The Mediterranean diet is rich in plenty of vegetables and fruit, cereal, nuts, legumes, fish, olive oil, and low in saturated fat, meat and sweets. A 2020 study of patients with Crohn’s disease and ulcerative colitis on the Mediterranean diet for 6 months found a significant reduction in malnutrition parameters, body mass index, clinical disease activity, reduced inflammation, improved gut microbiota balance, and improved quality of life. The researchers reported that the Mediterranean diet is effective for IBD patients as part of a multidimensional approach.
No clinical trials have been reported on this diet with IBD patients.
Eliminating various foods and nutrients from the diet should be done in consultation with your Physician and Registered Dietitian. Removing foods from your diet can increase the risk of malnutrition, weight loss and nutrient deficiencies.
Probiotics have received increasing attention from patients and researchers. Probiotics are defined by WHO as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”. However, the data are limited with respect to their efficacy for Crohn’s disease. The Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease notes that individual probiotics may prove useful, and further study is warranted.
World Gastroenterology Organisation Global Guidelines, 2017 provided the following recommendations for probiotics, which included specific probiotic strains and dosages.
“There is good evidence for the use of certain probiotics in preventing an initial attack of pouchitis, and in preventing further relapse of pouchitis after the induction of remission with antibiotics. Probiotics can be recommended to patients with pouchitis of mild activity, or as maintenance therapy for those in remission”.
“Certain probiotics are safe and as effective as conventional therapy in achieving higher response and remission rates in mild to moderately active ulcerative colitis in both adult and pediatric populations”.
“Studies of probiotics in Crohn’s disease have indicated that there is no evidence to suggest that probiotics are beneficial for the maintenance of remission of Crohn’s disease”.
Specific probiotic recommendations for IBD-C and IBD-UC are available in the Clinical Guide to Probiotics Available in Canada, 2020.
A prebiotic is defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit”. Prebiotics are frequently thought of as fibre, though not all fibres are prebiotic. Commonly known prebiotics are resistant starch, inulin, galactooligosaccharides (GOS), fructooligosaccharides (FOS), mannooligosaccharides (MOS) and xylooligosaccharides (XOS).
Small-scale prebiotic studies have been conducted, though further larger-scale trials are currently being planned.
Dietitians of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020 recommends additional prebiotic and probiotic research with studies with larger numbers of participants targeting specific disease states (active, in remission and with IBS-like symptoms.
Provincial Call Centres with access to speak to a Registered Dietitian free of charge:
Includes tips, recipes, meal and snack suggestions for healthy eating
Nutrition information, recipes, menus
Information written by Sandra Saville, RD
If you have recently been diagnosed with Inflammatory Bowel Disease (IBD) - Crohn’s disease or ulcerative colitis, you are likely to set sail on a journey of new self-discovery. While you can’t change your diagnosis, you can make informed choices so that you can live the best life possible. CDHF knows you may have a lot of questions, and we’re here to help! Empowerment starts with information – so let’s get started!
Inflammatory bowel disease (IBD) is at least two, separate disorders that cause inflammation (redness and swelling) and ulceration (sores) of the small and large intestines. These two disorders are called ulcerative colitis and Crohn’s disease.
Crohn’s disease can occur anywhere in the digestive tract but is common in the lower small bowel (ileum) or large bowel.
Ulcerative colitis is a chronic disorder affecting the large intestine (colon). The digestive system (including the stomach, small and large intestines) converts food into nutrients and absorbs them into the bloodstream to fuel our bodies. The colon’s main role is to absorb water and salts from undigested food waste. This action helps to thicken and solidify the stool, which is then expelled from the body through the anus.
Ulcerative colitis causes inflammation (redness and swelling) and ulceration (sores) along the lining of the colon, which can lead to abdominal pain, cramps, bleeding and diarrhea. The disease usually begins in the rectal area, which holds stool until you go to the bathroom, and may involve the entire colon over time. Ulcerative colitis is classified as an inflammatory bowel disease (IBD), due to the inflammation that occurs in the intestines. Another common form of IBD is called Crohn’s disease. Although the symptoms of ulcerative colitis are similar to Crohn’s disease, the conditions are different in several ways.
While both ulcerative colitis and Crohn’s disease are types of IBD, they should not be confused with Irritable Bowel Syndrome (IBS). IBS affects the muscle contractions and the sensitivity of the colon. Unlike ulcerative colitis and Crohn’s disease, IBS does not cause intestinal inflammation nor damage the bowel.
The exact cause of IBD is unknown. However, it is believed to be due to a combination of factors, including a person’s genes (inherited traits) and triggers in the environment. This interaction of genetic and environmental factors activates an abnormal response of the body’s immune system.
Normally, the immune system protects the body from infection. In people with ulcerative colitis, however, the immune system can mistake microbes (such as bacteria that are normally found in the intestines), food, and other material in the intestines, as invading substances.
When this happens, the body launches an attack, sending white blood cells into the lining of the intestines where they cause inflammation and ulcerations.
If you have just been diagnosed, it’s important to know that you are not alone. Canada has one of the highest incidences and prevalence rates of IBD in the world with more than 200,000 Canadians living with the disease.
IBD is a chronic (long-term) condition with symptoms that can disappear and then flare up again throughout your life. Living with the unpredictable nature of Crohn’s can pose physical and emotional challenges that may seem overwhelming at times. However, there are several things that you can do to contribute to your health and well-being.
Be informed, proactive, and involved in your care. By establishing a solid partnership with your health care team, developing coping skills, and maintaining a positive outlook, it is possible to stay healthy and happy, despite living with IBD.
Why me? There are common factors that increase your risk of developing the disease and severity.
If you have Crohn’s disease, you may experience periods of active symptoms (also referred to as a flare) and other times when symptoms are absent (remission). When you are in a flare, symptoms of Crohn’s disease can be painful and debilitating.
You may experience:
Why me? Research suggests that it may be a combination of factors including genetics and environment that causes your immune system to react in a harmful way.
People with UC may have:
IBD is a difficult disease to live with when it is flaring because the symptoms It causes can be painful, embarrassing and debilitating.
You may have heard your gastroenterologist or IBD nurse mention the term extraintestinal manifestation (extra-intestinal-manifestation) or EIM. EIMs are conditions that affect different parts of the body, outside of the gut, and may be related to your IBD inflammation. The exact cause of EIMs is not completely understood, so more research is needed. EIMs commonly affect the skin, eyes, mouth or joints. Individuals with IBD can experience an EIM prior to their diagnosis, and it’s also possible to develop an EIM while in remission.
EIMs can be quite common among pediatric IBD patients. Research has shown that 50% of patients with UC and 80% with Crohn’s will develop at least one EIM at some point in living with the disease[1]
Areas most commonly affected by EIMs:
Joint inflammation or arthritis, pronounced arth-ri-tis, is a common EIM of IBD and typically affects large joints like elbows, wrists, knees and ankles. Arthritis can cause pain, aching, stiffness and swelling in and around the joint(s).[2] Some patients can develop pain and swelling in small joints like the hands, fingers and feet, and others may experience arthritis in their hips or back. Most arthritis symptoms improve once gut inflammation is under control. Some IBD therapies are also used to treat arthritic conditions, which provides added management of symptoms for IBD patients affected by both conditions.
Erythema nodosum (EN), pronounced era-theema no-dough-sum, is a common condition that affects the fat under the skin. EN appears as tender, red bumps often on the ankles, upper or lower legs, or forearms. The condition is harmless but can be uncomfortable. EN tends to occur during flare-ups and can improve with IBD treatments. [3]
Psoriasis, pronounced sore-rye-a-sis, is another common skin condition. It causes cells to build up quickly on the skins surface, creating small, dry scaling red patches that can be itchy and can appear anywhere on the body. If scratched, these patches may bleed. Topical creams and ointments can be used to treat mild to moderate psoriasis. Photo or ultraviolet light is another therapy used to treat this skin condition. Some IBD medications also treat psoriasis which is an added benefit to those with both conditions.
Aphthous stomatitis, better referred to as canker sores or cankers, are one of the most common oral EIMs of IBD. Canker sores are small, often whitish bumps found anywhere inside the mouth. This includes the lips, the roof of the mouth, the cheeks and tongue, and they can be painful. IBD patients who experience cankers tend to get sores when their disease is more active. Sores can be minor and disappear within a week. For some, they can last longer and require steroid treatment.
Some IBD patients are affected by eye conditions, with the most common being episcleritis, pronounced ee-pis-kler-itis. This eye condition affects the layer of tissue covering the white outer coating of the eye (also called the sclera), making the eye red, sore and inflamed. Episcleritis may present during an IBD flare and can be treated with cold compresses. In some cases, steroid drops may be required.
Two additional eye conditions linked with IBD are scleritis (skler-it is), inflammation of the sclera itself, and uveitis (u-vee-it is), inflammation of the middle layer of tissue in the eye wall. These conditions are more serious and can lead to vision loss, if not treated. If you experience eye redness and pain to one or both eyes, contact your health care provider. They may ask you to be assessed by an eye specialist. Both scleritis and uveitis may be treated with steroid drops.
Bones play an essential role in our bodies. Not only do they give our body structure, but they also protect our internal organs and store an essential nutrient, calcium. Two important nutrients that contribute to the health of our bones are calcium, and vitamin D. Calcium helps build and maintain strong bones, while vitamin D helps absorb and retain calcium. When you have IBD, inflammation in the small intestine can impair nutrient absorption. In addition, certain medications used to treat flares can interfere with the body’s ability to absorb nutrients like calcium. When the body struggles to develop, build and maintain bone, the bones can become weaker.
There are different types of anemia, however the type most common among IBD patients is iron deficiency anemia (IDA). IDA can occur if there’s not enough iron in your diet, your body has difficulty absorbing iron from food, or you have ongoing blood loss from bowel inflammation. At your clinic appointment, your health care provider may order blood work to check your hemoglobin, vitamin D and inflammatory markers such as CRP. They like to check your iron level too. If it’s low, your health care provider may recommend that you eat more foods rich in iron, take an oral iron supplement, and in some cases, may prescribe an iron infusion.
The main symptom of anemia is tiredness or fatigue. When iron levels are very low, you may experience ongoing fatigue or tiredness along with headaches and general weakness. It is important to share these symptoms with your gastroenterologist so they can monitor and provide you with the best advice and treatment to manage anemia.
IBD is well known to affect the gastrointestinal tract, but EIMs can be just as troublesome to a person’s overall well-being with dramatic effects on a person’s quality of life. It’s important to share any symptoms that you may experience outside of your gastrointestinal tract, because they may or may not be related to a flare, and often times are treatable.
Works Cited:
Information from CDHF partner RobbiesRainbow.ca. For more information on IBD and children and/or teens visit RobbiesRainbow.ca. Melanie Watson contributed to the content and review of this article for accuracy and balance. Melanie Watson, MN, NP is a Nurse Practitioner- Pediatrics at the London Health Science Centre (LHSC), London, Ontario and has an adjunct appointment in the Arthur Labatt Family School of Nursing at Western University.
[1] Stawarski A, Iwanczak B, Krzesiek E, et al. Intestinal complications and extraintestinal manifestations in children with inflammatory bowel disease. Pol Merkur Lekarski 2006;20:22-5.[2] Arthritis society of Canada, What is Arthritis?[3] Jang et al. EIMs of pediatric IBD[4] http://www.ibdclinic.ca/what-is-ibd/ibd-and-bones/
There is currently no known way to prevent or for IBD, but the proper strategy for managing this disease can help you lead a happier, healthier, fulfilling life.
Words like Meditation and Mindfulness have been floating around in the media for quite some time now, and the question remains, can these practices help with IBD symptoms? Anyone with a chronic illness can attest to the fact that taking care of your physical health is only half of the battle.
Many chronic diseases & disorders such as IBD are triggered by stress. We also know that there is a direct brain-gut connection. Our digestive tracts can affect our mental health as much as our mental health can affect our digestive systems. So, it stands to reason that practicing things like Meditation and Mindfulness could really help with symptoms of IBD.
There has never been a more stressful time for the immunocompromised! With COVID-19 still plaguing the planet, and back to school coming up, many parents, teachers and students with chronic illnesses such as IBD are more stressed about their health than ever before. So, what are Mindfulness and Meditation? How does one go about including these practices into their everyday lives, and how can they help patients with chronic illnesses such as Inflammatory Bowel Disease?
While over the last few years, these terms have grown in popularity, especially in western culture, their meanings tend to be shrouded in skepticism and often regarded as a form of pseudo-science. However, there have been multiple studies done on the topic, that prove there is a great deal of benefits to practicing these two mental health maintenance strategies.
Practicing mindfulness is a form of therapy for the mind, that trains the brain in things like attentiveness and awareness. Over time, people who practice mindfulness regularly, can find a calm sense of consciousness in the present moment, alleviate anxiety triggers, identify negative emotions, their origins and accept these emotions and move forward with a renewed sense of control over their own minds (Rosenkranz, Melissa A, et al.)
In a review of 428 empirical studies on mindfulness intervention for chronic pain, only 8 were randomized controlled trials (Song, Yan, et al.). This implies that right off the bat, there’s not quite enough evidence yet to truly answer this question. However, the analysis of the 8 randomized and controlled trials showed that although Mindfulness and Mediation did not alleviate chronic pain, it DID greatly improve the psychological comorbidity of chronic pain.
This means that in patients with IBD and other disorders that cause chronic pain, there is a strong correlation between living with chronic pain and the patient’s psychological health (Workman, Edward A., et al.) By regularly practicing Mindfulness and Mediation, a marked improvement has been shown in those patients involved in the 8 randomized controlled trial studies, in accessory conditions to their chronic illness.
“Mindfulness intervention led to greater improvement in psychological comorbidity with chronic pain, such as depression …and trait anxiety.” (Song, Yan, et al.).
Knowing what we know about the impact stress and depression can have on a patient’s likelihood of reverting into a flare, this fact is worth exploring more. It is extremely important for patients with IBD to be able to recognize what they’re feeling and why they are feeling the way they are. These practices help patients accomplish this, and once they do, they are more likely to respond in a positive way to feelings of depression and anxiety and regain control over their mental health. More research needs to be done on the topic; however, the current evidence is promising!
There are tons of resources out there to help anyone get started with these practices. However, getting started is always a bit of a process, so we’ve done some research for you to deliver the best ways to get started if you’re new to practicing mindfulness and mediation.
Check out this great list by psycom.net to find some great resources to help you get started!
Works Cited
Eysenck, Michael W., et al. “Anxiety and Depression: Past, Present, and Future Events | Request PDF.” ResearchGate, www.researchgate.net/publication/247497269_Anxiety_and_depression_Past_present_and_future_events. Accessed 24 Aug. 2020.
Genentech. “A Mindful Approach to Chronic Disease.” Genentech: Breakthrough Science. One Moment, One Day, One Person at a Time., www.gene.com/stories/a-mindful-approach-to-chronic-disease. Accessed 24 Aug. 2020.
Rosenkranz, Melissa A, et al. “A Comparison of Mindfulness-Based Stress Reduction and an Active Control in Modulation of Neurogenic Inflammation.” Brain, Behavior, and Immunity, vol. 27, no. 1, 2013, pp. 174–84, www.ncbi.nlm.nih.gov/pubmed/23092711, 10.1016/j.bbi.2012.10.013. Accessed 22 Sept. 2019.
Rosenkranz, Melissa A., et al. “Reduced Stress and Inflammatory Responsiveness in Experienced Meditators Compared to a Matched Healthy Control Group.” Psychoneuroendocrinology, vol. 68, June 2016, pp. 117–125, 10.1016/j.psyneuen.2016.02.013. Accessed 17 Feb. 2020.
Song, Yan, et al. “Mindfulness Intervention in the Management of Chronic Pain and Psychological Comorbidity: A Meta-Analysis.” International Journal of Nursing Sciences, vol. 1, no. 2, 1 June 2014, pp. 215–223, www.sciencedirect.com/science/article/pii/S2352013214000490, 10.1016/j.ijnss.2014.05.014. Accessed 24 Aug. 2020.
Workman, Edward A., et al. “Comorbid Psychiatric Disorders and Predictors of Pain Management Program Success in Patients With Chronic Pain.” Primary Care Companion to The Journal of Clinical Psychiatry, vol. 4, no. 4, 2002, pp. 137–140, www.ncbi.nlm.nih.gov/pmc/articles/PMC315482/. Accessed 24 Aug. 2020.
Zeidan, F., et al. “Mindfulness Meditation-Related Pain Relief: Evidence for Unique Brain Mechanisms in the Regulation of Pain.” Neuroscience Letters, vol. 520, no. 2, June 2012, pp. 165–173, 10.1016/j.neulet.2012.03.082. Accessed 7 Oct. 2019.
Dr Mary Zachos, pediatric gastroenterologist at McMaster Children’s Hospital, offered up some insightful advice for IBD patients, addressing some commonly asked questions in regards to sexuality and IBD.
Do IBD medications affect body image?
Most medications we currently use to treat IBD do not change how a person looks. However, corticosteroids are occasionally used and can cause temporary side effects, including weight gain, acne or increased hair growth.
Do certain medications affect sex drive?
They do not. However, some medications can decrease energy levels - as can active disease symptoms. Consequently, the desire for sex might be reduced.
Does an ostomy impact body image and sexual functioning?
Although an ostomy itself does not impact sexual functioning, having an ostomy or surgical scar can make a person feel even more insecure. Your healthcare team and ostomy nurse can offer sound advice to help you manage the ostomy apparatus during intimacy.
Are there any risks with respect to sex and IBD?
All individuals - whether they have IBD or not - take on certain risks when they have sex, including contracting a sexually transmitted infection (STI), becoming pregnant or making someone else pregnant. However, these can have greater consequences in people with IBD. For example, some IBD medications affect the immune system, and STIs can; therefore be
more severe in people with IBD. In addition, certain medications are not safe for fetal development and should be strictly avoided if there is any risk of pregnancy. Young women should also consider being vaccinated against HPV, a sexually transmitted virus that can increase the risk of cervical cancer.
Can a person with IBD have a normal sex life?
Just because you have IBD does not mean you cannot have a healthy sex life, you can! However, you might just not feel well enough to be interested in sex during flares. Some types of IBD can affect the area around the vagina or anal canal with a fistula or abscess, which can make sex uncomfortable or even painful. It can be beneficial to speak to your healthcare team about any discomfort or worries regarding sex.
Does IBD affect puberty?
Active IBD can delay puberty in the same way it can have effects on growth. In some people, the main manifestation of disease activity is its effect on growth and pubertal development, and gastrointestinal symptoms are minimal. Therefore, in addition to reviewing symptoms and having tests such as blood work, stool analysis, imaging and endoscopy/colonoscopy, an important part of monitoring IBD is keeping a close eye on pubertal development.
How should parents approach the topic of sex?
“A parent should aim to create open lines of communication and approachability about all aspects of life, including school, relationships and behaviours. This will make it easier to have the same openness about sexuality. This communication needs to begin in early childhood and continue in a positive, non-judgmental and trustworthy fashion, so your teen with IBD will feel comfortable approaching you, or a healthcare team member with questions about sex.”
Information from CDHF partner RobbiesRainbow.ca. For more information on IBD and children and/or teens visit RobbiesRainbow.ca.
Date Written: 09-2020
This information is intended for educational purposes and is not intended to replace recommendations that have been provided by your Physician and Health Care Team. Healthy eating objectives for IBD include managing symptoms, ensuring and optimizing adequate intake, promoting healing, reducing complications and meeting other relevant personal needs.
There is no miracle cure for Crohn’s and ulcerative colitis, through a special diet, food combinations, or exclusions of select foods or nutrients. Individuals with IBD, including Crohn’s disease and ulcerative colitis may feel well, or ill during a flare-up, leading to variations in appetite and nutritional intake depending on the state of their IBD.
During a flare-up and even when feeling well, it is important to be well-nourished to support healing, build strength, reduce inflammation and optimize nutritional intake. If you feel ill during a flare-up, making effective changes to diet may potentially help you to manage symptoms.
You may find some improvements or worsening in your symptoms based on certain foods. Keep a diary, it is worth tracking food intake to try and determine possible symptom triggers. However, it is important to assess whether other factors like stress, hormones, level of sleep and physical activity contribute to worsening of symptoms rather than merely foods as the cause.
Take the time to track your symptoms in the CDHF app that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.
Canada’s Food Guide is a tool that can be used to guide your meal and snack choices. Consuming a variety of vegetables and fruits, whole grains, lean meat and protein choices provides a range of vitamins and minerals that you need daily.
Aim to fill half the plate with a variety of vegetables and fruit, fill one-quarter of the plate with healthy whole grains like bread, unsweetened cereals, pasta, rice and quinoa. Fill the remaining quarter of the plate with protein, including lean meat, poultry, fish, eggs, soy, dairy and non-dairy fortified milk, yogurt and cheese.
If your appetite is low, consume small frequent meals and snacks to consume adequate intake and prevent malnutrition.
Consume adequate amounts of fluid intake to move wastes through your system and prevent dehydration.
If your diet intake is inadequate due to poor appetite, reduced intake, or malabsorption and difficulty meeting nutritional needs, discuss strategies with your Physician and Registered Dietitian. Consuming small frequent meals and snacks, high-calorie foods, or supplements like Ensure or Boost may be beneficial.
Daily fibre intake and goals should be discussed with your Physician, especially for those with Crohn’s disease with strictures and at risk of a bowel obstruction.
Dietitian’s of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020, does not recommend a high fibre nor a low fibre diet to help manage Crohn’s disease, either active or in remission, so it is best to maintain normal fibre intake.
Health Canada recommends Canadian women consume 25 grams of fibre/day and men consume 38 grams of fibre/day, though most Canadians are consuming about half that requirement.
Some people find fibre to improve their symptoms of constipation, yet others find fibre tends to irritate their symptoms during a flare. If you have concerns or questions about your fibre intake, consult your Physician or Registered Dietitian.
During a flare-up, protein needs are higher. Increase protein intake at meals, and with snacks, including meat, fish, poultry, soy and soy products like tofu, dairy and fortified non-dairy milk, yogurt and cheese, plain nuts and seeds and nut and seed butters.
Typical portion servings are about the size of a regular deck of playing cards, 2 tablespoons of nut butter, ¼ cup of plain nuts or 2 eggs.
Adults should consume 2-3 tablespoons of healthy fats in cooking and in foods throughout the day. Unsaturated fats like olive oil, avocado oil, omega-3 found in fatty fish like salmon, sardines, trout as well as plain nuts are all healthy choices.
Some common nutrients of concern for adults with IBD, and select food sources containing the nutrients:
Source: Dietitians of Canada. 2019. PEN. Inflammatory Bowel Disease in Adults.
Certain medications (methotrexate and sulphasalazine) can increase the need for folic acid supplements.
Some individuals have increased nutrients needs, including calcium, iron, and vitamin D. Discuss your specific needs, including potential benefits of vitamin supplements with your Physician or Registered Dietitian. Regular screening for iron deficiency anemia may be advised.
You could temporarily remove one food from your diet at a time to see if your gas symptoms improve.
If you find some dairy products cause gas and bloating, it could be due to lactose. Some people, particularly during a flare-up, may become intolerant to lactose, the sugar in dairy products. A lactose-free diet may help to alleviate symptoms. Look for lactose on food labels and buy lactose-free dairy products. The lactose intolerance may be temporary. Some of the symptoms of lactose-intolerance are like a flare-up, so before altering your diet, discuss your symptoms with your Physician.
Unless you have symptoms to specific foods, do not remove them from your diet. Everyone is different, and what causes issues for one person may not have the same reaction for others. If you remove foods from the diet, make sure to check your tolerance to these foods from time to time, as symptoms can vary over time. Also, restricting foods can lead to extensive lists of foods excluded from the diet, which can increase the risk of nutrient deficiencies.
If a low FODMAP diet is advised by your Physician, consult with a Registered Dietitian who has expertise with the diet. This diet is meant to only be temporary for just a few weeks, then foods are added back into the diet systematically to expand nutritional intake. Following the low FODMAP diet for longer than a few weeks can have negative effects on the body. The FODMAPs are food for the microbes that reside in your intestine and provide health benefits. Staying on this diet can have negative effects on your microbiome (microbes). The low FODMAP diet may be effective in helping you, and your Registered Dietitian determine what foods potentially trigger your symptoms.
The Mediterranean diet is rich in plenty of vegetables and fruit, cereal, nuts, legumes, fish, olive oil, and low in saturated fat, meat and sweets. A 2020 study of patients with Crohn’s disease and ulcerative colitis on the Mediterranean diet for 6 months found a significant reduction in malnutrition parameters, body mass index, clinical disease activity, reduced inflammation, improved gut microbiota balance, and improved quality of life. The researchers reported that the Mediterranean diet is effective for IBD patients as part of a multidimensional approach.
No clinical trials have been reported on this diet with IBD patients.
Eliminating various foods and nutrients from the diet should be done in consultation with your Physician and Registered Dietitian. Removing foods from your diet can increase the risk of malnutrition, weight loss and nutrient deficiencies.
Probiotics have received increasing attention from patients and researchers. Probiotics are defined by WHO as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”. However, the data are limited with respect to their efficacy for Crohn’s disease. The Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease notes that individual probiotics may prove useful, and further study is warranted.
World Gastroenterology Organisation Global Guidelines, 2017 provided the following recommendations for probiotics, which included specific probiotic strains and dosages.
“There is good evidence for the use of certain probiotics in preventing an initial attack of pouchitis, and in preventing further relapse of pouchitis after the induction of remission with antibiotics. Probiotics can be recommended to patients with pouchitis of mild activity, or as maintenance therapy for those in remission”.
“Certain probiotics are safe and as effective as conventional therapy in achieving higher response and remission rates in mild to moderately active ulcerative colitis in both adult and pediatric populations”.
“Studies of probiotics in Crohn’s disease have indicated that there is no evidence to suggest that probiotics are beneficial for the maintenance of remission of Crohn’s disease”.
Specific probiotic recommendations for IBD-C and IBD-UC are available in the Clinical Guide to Probiotics Available in Canada, 2020.
A prebiotic is defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit”. Prebiotics are frequently thought of as fibre, though not all fibres are prebiotic. Commonly known prebiotics are resistant starch, inulin, galactooligosaccharides (GOS), fructooligosaccharides (FOS), mannooligosaccharides (MOS) and xylooligosaccharides (XOS).
Small-scale prebiotic studies have been conducted, though further larger-scale trials are currently being planned.
Dietitians of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020 recommends additional prebiotic and probiotic research with studies with larger numbers of participants targeting specific disease states (active, in remission and with IBS-like symptoms.
Provincial Call Centres with access to speak to a Registered Dietitian free of charge:
Includes tips, recipes, meal and snack suggestions for healthy eating
Nutrition information, recipes, menus
Information written by Sandra Saville, RD
First things first. Let’s go over the language of treatment options.
Researchers and doctors often use the term “adherence” or “compliance” to describe how well patients follow the treatment they have been prescribed. This can include taking medication at the proper times, taking all of the medication, refilling prescriptions and going to appointments for infusion or injections faithfully.
The word “flare” refers to the symptoms you experience when your disease is active and causing tissue to become inflamed and irritated. The most common symptoms of IBD flares are abdominal pain and bloody diarrhea. Common symptoms also include weight loss, fatigue, fever, aching joints, skin and mouth sores, and inflamed eyes.
Complications are additional ailments that you may experience as a result of living with a chronic disease. When you have IBD, you may experience:
When you have IBD, the interior layer of tissue lining your intestine (called the mucosa) gets damaged. Mucosal healing is the restoration of healthy mucosa.
Another challenge of living with IBD is the development of abnormal connections between your intestine and other organs. These are called fistulas. Proper medication may help reduce the likelihood of developing fistulas.
As mentioned, there is no cure for inflammatory bowel disease at the present time; however, there are effective treatments available that may control your disease and even place it into remission. Remission means that your symptoms disappear completely.
Medication(s) are chosen specifically for YOU based on your history and severity of disease. It is important you speak openly and regularly with your doctor so you can make the best decisions for your health – together.
Biologic drugs (also called reference or originators) are medications made by using living organisms (such as yeast or animal cells) to produce complex proteins that are purified then administered to affect certain processes in the human body.
A biosimilar is a drug proven to be highly similar to its copy, a reference biologic, and has been authorized for sale in Canada. Biosimilars can only come to market after the 20-year patient protection on a reference biologic drug has ended.
No. Reference biologics and biosimilars are complex molecules made from living cells. Due to this fact, biosimilars are highly similar, but not identical versions, of their reference biologic drugs.
Generic medications are exact copies of a brand-name drug. Generics contain the same chemical substance(s) as branded drugs and provide the same therapeutic effect. Biosimilars are similar to but not exact copies of a reference biologic. The difference lies in the inactive components within the product. Because biologics and biosimilars are made with living cells, and not chemicals, they are more complex and have a natural variability.
These slight variations exist within ALL biologic and biosimilar medications, including batches of reference biologics that have been on the market for years. Biologics and biosimilars must meet Health Canada’s safety, immunogenicity, and efficacy requirements.
As well, it must be developed and manufactured following the same strict quality requirements as any other biologic; therefore, delivering the same therapeutic benefits as its reference biologic.
In addition to medication to control inflammation, your doctor may recommend additional products to help relieve your symptoms, including antibiotics (for fever), pain relievers (for abdominal pain), antidiarrheals (to control diarrhea) and iron supplements (for anemia). Talk to your doctor about which medications are safe for you to take.
This has become a standard regime recommended by GI's as concomitant therapy.
Studies have found that, in some cases, probiotics may help to improve symptoms of IBD. Probiotics are live microorganisms that, when taken in adequate amounts over sufficient time, may provide a health benefit. They are natural, ‘healthy’ bacteria that may help with digestion and offer protection from harmful bacteria in the intestines.
Probiotics are not medicine. They are available to purchase as capsules, tablets or powders, and can also be found in some fortified yogurts and fermented milk products. However, not all probiotics are the same. Although many products claim to have benefits, only two probiotics formulations – E. coli Nissle and VSL#3 – have been shown to be effective in ulcerative colitis and pouchitis.
Ask your doctor or pharmacist if one of these formulations may be right for you. It is important to take the probiotic in the dose and duration recommended by the manufacturer to achieve the best results.
People with both Crohn’s disease and ulcerative colitis may need surgery at some point in their lives. Surgery is less common in ulcerative colitis than in Crohn’s disease and is often performed when ulcerative colitis is no longer responding to medical treatment.
Unlike Crohn’s disease, surgery will cure ulcerative colitis by removing all diseased bowel. With the colon being completely removed, the patient may require an ileostomy (bag outside the body to collect waste) or a second operation to form a new rectum (called a pouch procedure). Despite all of the advances in medical research over the last several decades, we still do not know the cause of IBD and much further research is required.
We had compiled a number of patient stories of when they were originally diagnosed and what they do to manage their day-to-day. Please keep in mind everyone is different when it comes to IBD.
Am I going to get cancer because I have IBD?
People with IBD are at an increased risk of developing colon cancer. Having regular colonoscopies will help identify polyps that could potentially develop into cancer.
Does diet affect (IBD)? Maybe move this up to the diet section?
Diet alone is not effective in treating Crohn’s disease or ulcerative colitis. However, it is important patients with IBD have a well-balanced diet. Calcium is important to protect bones. Fibre may not be tolerated during flare-ups. Certain vitamins (for example, B12) may be required. Selected patients may sometimes be helped by a registered dietician.
How is IBD different than IBS?
Although both illnesses can be seriously debilitating, there are several primary differences between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). IBD is an autoimmune disorder that causes swelling and ulcerations (sores) in the bowel. IBS involves problems with motility (how the bowel moves contents through our intestines) and sensitivity (how the brain interprets sensations in the bowel). Symptoms of IBS may wax and wane and possibly disappear altogether, whereas IBD is a chronic condition.
How can I tell if my treatment is working?
For some people, IBD symptoms will significantly improve within a short time after starting medication or making lifestyle and dietary changes. For others, finding relief from symptoms is a slow process, and it may take longer for a definite improvement to be noticed. It is important for you and your doctor to work together to determine what triggers your symptoms and to find the right treatment to manage your symptoms effectively.
How can I prepare for an appointment with my GI to discuss my ulcerative colitis or Crohn’s disease?
Good communication with your doctor is an important part of effective management of a gastrointestinal disorder such as IBD. Before your appointment, take the time to keep a symptom journal that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms. Include the following information in your journal:
Also, create a list of questions to ask your doctor during your appointment. Specifically, you may want to ask your doctor questions such as:
Not showing symptoms for COVID-19? You should still be taking care to practice social distancing!
The fact of the matter is, even if you’re not showing any symptoms, you can pass this virus on to people who ARE at risk. This not only means the elderly in our community, but people who are have compromised immune systems. Many IBD patients, for example, are on medications that suppress the immune system, and it’s times like these that we need to band together and think of our neighbours. People who suffer from a chronic underlying conditions chronic respiratory illnesses, diabetes, cancer, etc are also at risk. We must be proactive now and get in front of this pandemic.
Practicing social distancing is the best way possible to keep this virus from spreading and potentially harming more people in our community. If you are not taking immunosuppressive medications and your condition is currently in remission, you are at the same level of risk as the general public, according to Crohn’s and Colitis Canada. However, if you are taking an immunosuppressive medication, make sure to continue taking your medications and prioritize social distancing as soon as you can.
If you are not showing any symptoms, please refrain from any in person visits with a doctor. Healthcare professionals will be working day and night to help the infected, and they must prioritize at risk patients. If we all take care and do our best to protect one another by following the advice of the Public Health Agency of Canada, we have to potential to save countless lives while we wait for a viable vaccine.
We know there’s a lot of information being shared online, so we have decided to make a list of relevant links to help you easily find the best resources for you:
You can learn more about health and safety recommendations for patients by going to the Crohn’s and Colitis web page here: https://crohnsandcolitis.ca/Living-with-Crohn-s-Colitis/COVID-19-and-IBD
Health Canada also has information and recommendations for the general public on how to safely navigate this pandemic.https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html
For additional information about COVID-19 in your area, please visit the links below:
Federal COVID-19 information
Travel Advice and Advisories
Ontario COVID-19 information
British Columbia COVID-19 information
Quebec COVID-19 information
Alberta COVID-19 information
New Brunswick COVID-19 information
Newfoundland and Labrador COVID-19 information
Nova Scotia COVID-19 information
Prince Edward Island COVID-19 information
Manitoba COVID-19 information
Saskatchewan COVID-19 information
Yukon COVID-19 information
Northwest Territories COVID-19 information
Nunavut COVID-19 information
As of 2018, 270,000 Canadians are living with IBD, with one of the highest incidence (number of new cases per year) & prevalence (total number of people diagnosed) rates in the world. IBD affects people of all ages, with the peak onset of 15-35 years for Crohn’s disease, and usual onset of 15-45 years for ulcerative colitis, both carrying the diagnosis through reproductive years.
If you or your loved one has IBD, and want to start a family, there are several considerations to keep in mind to ensure a healthy, happy pregnancy.
[flipbook pdf="https://cdhf.ca/wp-content/uploads/2020/11/Pregnancy-an-IBD-infographic-V6-1.pdf"]
Both biologics and biosimilars have gone through rigorous standards for authorization by Health Canada, to which both have been found safe and effective for use in Inflammatory Bowel Disease (IBD).
CDHF knows having to change any kind of medication can be very stressful. CDHF's Biosimilar library has many informative resources to help make your transition to your new medication seamless.
A biosimilar is a drug proven to be highly similar to a biologic drug that has been authorized for sale in Canada (known as the reference biologic drug). Biosimilars have been approved by Health Canada based on a thorough comparison to a reference biologic drug and may enter the market after the reference biologic drugs’ patents and data protection has expired. Biosimilar products first entered the Canadian market in 2009. Health Canada has already approved over 30 biosimilars, including some that are used to treat IBD (Crohn’s disease and ulcerative colitis): Inflectra (infliximab), Renflexis (infliximab), Avsola (infliximab), Hadlima (adalimumab), Idacio (adalimumab), Hyrimoz (adalimumab), Amgetiva (adalimumab) and Hulio (adalimumab).
To be approved in Canada, a biosimilar must be proven to have no clinically meaningful differences to the reference biologic. This means, studies of the biosimilar MUST show that there are no differences in outcomes for patients taking a biosimilar, compared to those taking a reference biologic drug. Rigorous standards for authorization by Health Canada mean that patients and health care providers can have the same confidence in the quality, safety and efficacy of a biosimilar.
Health Canada supports switching from a biologic to a biosimilar and considers that a one-time switch from a reference biologic drug to a biosimilar to be acceptable. Health Canada also recommends that the decision to switch be made by the physician/prescriber and patient, taking into account any policies of the relevant jurisdiction.
[flipbook pdf="https://cdhf.ca/wp-content/uploads/2021/04/CDHF-EnglishBiosimilarTransitionPathwayBrochure.pdf"]
CDHF wants to understand the recent experiences of people living in Canada who have switched/transitioned from Remicade® (infliximab) to the biosimilar versions of infliximab: Inflectra® and Renflexis™.
If you haven't been asked to switch/transition yet, please note that we will keep this survey open for a few months so you can come back to it and complete it.
This survey is only for people living in the Canada, aged 18+ who have switched/transitioned from the biologic Remicade® to the biosimilar Inflectra® or Renflexis™.
Good communication with your doctor is an important part of effective management of a gastrointestinal disorder such as IBD. Before your appointment, take the time to keep a symptom journal that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms. Include the following information in your journal or CDHF App!
Also, create a list of questions to ask your doctor during your appointment. Specifically, you may want to ask your doctor questions such as:
Deadline date change: The deadline for patients taking a biologic drug to switch to a biosimilar version has been changed from July 1, 2020 to January 15, 2021 due to the COVID-19 pandemic.
As of January 15, 2021 Alberta Health will only cover the biosimilar versions of infliximab: Inflectra and Renflexis, for patients living with Crohn’s disease or ulcerative colitis. Those who wish to maintain their Alberta Health coverage for the drug molecule will be required to switch from a biologic drug to the biosimilar by January 15, 2021, to avoid any disruption to coverage.
This initiative will apply to adult members enrolled in one of these government sponsored drug plans provided through Alberta Blue Cross:
Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Learners Program (Group 22128)
Assured Income for the Severely Handicapped (Group 19823)
Alberta Adult Health Benefit (Group 23609)
If you are currently receiving Remicade® to treat your Crohn’s disease or ulcerative colitis and you depend on Alberta Health coverage, you need to contact with your health care professional to discuss this policy change. An exceptions process will be in place should your prescriber believe there is a medical reason why a patient cannot switch to a biosimilar. For individuals starting a biologic or changing their biologic drug, a tiered framework will apply, requiring patients to try a number of first-line therapeutic options prior to being able to access a second-line agent. Patients and health providers will still have numerous treatment options, including other biologics, covered through the government sponsored drug plans.
A biosimilar is a drug proven to be highly similar to a biologic drug that has been authorized for sale in Canada (known as the reference or originator biologic drug).
Biosimilars have been approved by Health Canada based on a thorough comparison to a reference biologic drug and may enter the market after the reference biologic drugs’ patents and data protection has expired.
Biosimilar products first entered the Canadian market in 2009. Health Canada has already approved over 30 biosimilars, including some that are used to treat IBD (Crohn’s disease and ulcerative colitis): Inflectra (infliximab), Renflexis (infliximab), Avsola (infliximab), Hadlima (adalimumab), Idacio (adalimumab), Hyrimoz (adalimumab), Amgetiva (adalimumab) and Hulio (adalimumab).
To be approved in Canada, a biosimilar must be proven to have no clinically meaningful differences to the reference biologic. This means, studies of the biosimilar MUST show that there are no differences in outcomes for patients taking a biosimilar, compared to those taking a reference biologic drug.
Rigorous standards for authorization by Health Canada mean that patients and health care providers can have the same confidence in the quality, safety and efficacy of a biosimilar.
Health Canada supports switching from a biologic to a biosimilar and considers that a one-time switch from a reference biologic drug to a biosimilar to be acceptable. Health Canada also recommends that the decision to switch be made by the physician/prescriber and patient, taking into account any policies of the relevant jurisdiction.
Once you have switched to a biosimilar version of Remicade® (infliximab) please take our patient survey.
1. What is a Biologic?
Biologic (reference) drugs are medications made by using living organisms (such as yeast or animal cells) to produce complex proteins that are purified then administered to affect certain processes in the human body.
2. What is a Biosimilar?
A biosimilar is a drug demonstrated to be highly similar to a biologic (reference) drug, that has been authorized for sale in Canada.
3. What do experts say about the safety and efficacy of biosimilars?
Health Canada is responsible for ensuring the safety, efficacy, and quality of all new drugs including biologics and biosimilars. For a biosimilar drug to be approved in Canada, Health Canada must find no meaningful differences in safety and effectiveness compared to the biologic.
4. Do I have to switch to a biosimilar?
If you receive coverage through Alberta Health and you currently take Remicade® for the treatment of Crohn’s disease or ulcerative colitis, you must switch to the biosimilar version before the end of the transition period (January 15, 2021) to avoid any disruption to your coverage.
There may be medical reasons why some patients cannot switch to a biosimilar. Your gastroenterologist can help you determine if it is medically necessary to remain on a biologic (originator) drug. An exception process will be in place should a prescriber believe there is a medical reason why their patient cannot switch to a biosimilar.
5. Why is the change happening?
Alberta spent more than $238 million in the 2018 to 2019 fiscal year on biologic drugs, and these costs are increasing every year. Costs per patient for originator biologics can be more than $25,000 per patient per year, with biosimilar versions costing up to 50% less than originator biologics.
Alberta is implementing the Biosimilar Initiative which will save approximately $30 million annually that can be invested into other health care services for Albertans.
6. How do I maintain my Infliximab® coverage?
To maintain your coverage:
Since its launch, the Initiative has successfully switched many PharmaCare patients to an approved biosimilar drug.
Each switch period is six months. If you are taking one of the originator drugs and it is covered by PharmaCare, and you don’t want to lose your coverage, speak to your prescriber before the switch period ends. Your prescriber can write you a new prescription, for the biosimilar, and your coverage will continue until the drug’s renewal date. After the switch period ends, PharmaCare only covers the biosimilar version(s).
BC PharmaCare coverage has changed for people who take Remicade® and Humira® for the treatment of Crohn’s disease or ulcerative colitis.
Patients currently receiving the biologic drug Humira® will see coverage discontinued, with new coverage provided for the biosimilars versions.
Between April 7, 2021 to October 6, 2021 anyone with existing Special Authority coverage for Humira® will be required to switch to the biosimilar versions Idacio®, Amgevita™, Hadlima®, Hyrimoz®, Hulio®.
Patients currently receiving the biologic drug infliximab, marketed as Remicade®, will see this coverage discontinued, with new coverage provided for the biosimilar versions of infliximab: Inflectra® and Renflexis™.
If you are currently receiving Remicade® to treat your Crohn’s disease or ulcerative colitis and you depend on BC PharmaCare coverage, you need to make an appointment with your gastroenterologist (GI) to discuss this policy change.
Between September 5, 2019 and March 5, 2020 anyone with existing Special Authority coverage for Remicade® will be required to switch to either Inflectra® or Renflexis™.
As of March 6th, 2020, BC PharmaCare will only cover the biosimilar versions of infliximab: Inflectra® and Renflexis™, for patients living with Crohn’s disease or ulcerative colitis.
BC Pharmacare will consider requests from physicians for patients with exceptional medical requirements that may prevent them from switching to a biosimilar.
A biosimilar is a drug proven to be highly similar to a biologic drug that has been authorized for sale in Canada (known as the reference or originator biologic drug).
Biosimilars have been approved by Health Canada based on a thorough comparison to a reference biologic drug and may enter the market after the reference biologic drugs’ patents and data protection has expired.
Biosimilar products first entered the Canadian market in 2009. Health Canada has already approved over 30 biosimilars, including some that are used to treat IBD (Crohn’s disease and ulcerative colitis): Inflectra (infliximab), Renflexis (infliximab), Avsola (infliximab), Hadlima (adalimumab), Idacio (adalimumab), Hyrimoz (adalimumab), Amgetiva (adalimumab) and Hulio (adalimumab).
To be approved in Canada, a biosimilar must be proven to have no clinically meaningful differences to the reference biologic. This means, studies of the biosimilar MUST show that there are no differences in outcomes for patients taking a biosimilar, compared to those taking a reference biologic drug.
Rigorous standards for authorization by Health Canada mean that patients and health care providers can have the same confidence in the quality, safety and efficacy of a biosimilar.
Health Canada supports switching from a biologic to a biosimilar and considers that a one-time switch from a reference biologic drug to a biosimilar to be acceptable. Health Canada also recommends that the decision to switch be made by the physician/prescriber and patient, taking into account any policies of the relevant jurisdiction.
1. What is a Biologic?
Biologic (reference) drugs are medications made by using living organisms (such as yeast or animal cells) to produce complex proteins that are purified then administered to affect certain processes in the human body.
2. What is a Biosimilar?
A biosimilar is a drug demonstrated to be highly similar to a biologic (reference) drug, that has been authorized for sale in Canada.
3. What do experts say about the safety and efficacy of biosimilars?
Health Canada is responsible for ensuring the safety, efficacy, and quality of all new drugs including biologics and biosimilars. For a biosimilar drug to be approved in Canada, Health Canada must find no meaningful differences in safety and effectiveness compared to the biologic. The biosimilars involved in BC PharmaCare’s Biosimilars Initiative have been approved by Health Canada and are already in widespread use.
4. Do I have to switch to a biosimilar?
If you receive coverage through BC PharmaCare and you currently take Remicade® for the treatment of Crohn’s disease or ulcerative colitis, you must switch to the biosimilar version before the end of the transition period (March 5, 2020) to avoid any disruption to your coverage.
There may be medical reasons why some patients cannot switch to a biosimilar. Your gastroenterologist can help you determine if it is medically necessary to remain on a biologic (originator) drug. Your gastroenterologist can submit a Special Authority Request to ask BC PharmaCare to consider continued coverage of the reference biologic drug.
5. What are the benefits of biosimilars?
Biosimilars are developed and approved based in part on data generated during the research and development of the reference biologic drug. Extensive structural and functional studies demonstrate a high degree of similarity between the biosimilar and reference biologic drug, with clinical trials in humans confirming no clinically meaningful difference in efficacy. The difference in development processes allow for biosimilars to be launched at lower prices than the reference biologics representing the potential for major cost savings that can be reinvested into the healthcare system.
Due to the cost savings provided by biosimilars, the launch of infliximab biosimilars in Canada allowed Ulcerative Colitis patients in BC, QC, NB, NS, and NL to have access to infliximab for the first time. The reference biologic (Remicade®) was not covered for Ulcerative Colitis in these provinces.
A healthy and competitive drug market can support more manufacturers to produce new and affordable drugs. Biosimilars will enable patients to have access to many other life-saving treatments. Phase 1 of BC Biosimilar Initiatives allowed BC Pharmacare to cover 2 new innovative medicines for patients with diabetes and psoriatic arthritis (Taltz and Jardiance). Phase 1 also provided Accelerated Access to biologics for Rheumatology patients. Both British Columbia and Alberta Public drug plans implemented biosimilar transition policies in 2019. This resulted in tens of thousands of patients being transitioned to a biosimilar. Part of the savings from the BC policy ($120 million over 3 years) have been reinvested to improve patient care. This includes the reimbursement of new, innovative drugs, additional nursing support for all inflammatory bowel disease (IBD) patients and for the fecal calprotectin diagnostic test to be covered for all IBD patients in the province.
6. Why is coverage changing in BC?
As new treatments are developed, BC PharmaCare must review which drugs are covered and carefully consider how to best meet the needs of B.C. residents. Since the introduction of biologic drugs in the 1980s, these treatments have become the biggest drug expense in Canada. As patents on biologic drugs begin to expire, other manufacturers can start producing highly similar versions of the medication with no differences, at a much lower cost. These versions are called biosimilars. Remicade is B.C.’s second largest biologic expense. By switching to a biosimilar version, you are helping save millions of dollars every year. This is an opportunity to maximize resources, expand coverage for new treatments, and improve patient access to more medications.
7. How do I maintain my Infliximab® coverage?
To maintain your coverage:
8. Are there patient support programs?
Yes. Biosimilar manufacturers are providing patient support programs (PSP) and services, and access to infusion centres similar to that of the reference biologic drug . Your prescriber can initiate the enrolment process into a PSP for you, if applicable.
#CDHFTalks: Your New Infusion Clinic 'Not the Same but Very Similar.' Have you recently been diagnosed with Inflammatory Bowel Disease (IBD): Crohn's disease or ulcerative colitis and have been prescribed a biosimilar, or have recently switched from a biologic drug to a biosimilar? As you may or may not know, most biologic and biosimilar drugs are administered by Infusion which typically means that the drug is given through an IV (where a short needle is inserted into the layer of tissue between the skin and the muscle).
You might be receiving your infusion at an infusion clinic, and if you are newly diagnosed with IBD and new to the whole idea, we know you may have MANY questions. Similarly, if you have recently had to change infusion clinics for one reason or another, you may also have a ton of questions about what the experience will be like at your new infusion clinic.
In this CDHF Talks, Dr. Sean Pritchett, MD, Dr. Yvette Leung, Gastroenterologist, Athena Robitaille, BScN, RN, and Katelyn Syms, BScN, RN answer all of the questions you may have in regards to your new infusion clinic, and take you through a typical infusion at a real infusion clinic!
Helping inflammatory bowel disease (IBD) patients best understand transitioning/switching from a reference biologic to a biosimilar.
[flipbook pdf="https://cdhf.ca/wp-content/uploads/2021/04/CDHF-EnglishBiosimilarTransitionPathwayBrochure.pdf"]
Updated March 2021
Having to change any kind of medication can be very stressful. While CDHF believes in patient-physician choice, we acknowledge political policy decisions and our organization is committed to providing clear and unbiased information and resources for patients. Both biologics and biosimilars have gone through rigorous standards for authorization by Health Canada, to which both have been found safe and effective for use in Inflammatory Bowel Disease (IBD). Watch this video to learn more about switching from a biologic to a biosimilar.
CDHF is SO excited to share Robbie’s Rainbow’s latest edition of “You, Me and IBD” – an educational IBD magazine for children, teens, and parents, in partnership with yours truly!
With articles on managing IBD, personal stories, healthy recipes, and fun activities, this magazine is jam packed with helpful information for children, teens, and parents of those with IBD.
Robbie’s Rainbow is a registered charity with a sole focus on childhood Inflammatory Bowel Disease (IBD). Their charity provides access to medical treatments, procedures and care not covered by private or public health plans and they build educational resources for IBD children and their families.
Making informed decisions is imperative to your good health but understanding the benefits and risks associated with Crohn's Disease treatment options can be challenging. CDHF developed the IBD BRAT - a tool to help you learn more about common risks as well as important benefits around the therapy options. Check out our detailed online version by clicking here, or download the coles notes version below!
