Question:
Is there a "best" preparation for a colonoscopy? I hate everything my gastroenterologist has prescribed. Any tricks to making this tolerable? Should I even have a colonoscopy if my disease is active?

Dr. Korzenik:
The “best” prep is whatever works to get the colon clean and there are many choices. You are having the scope done so your doctor can get as clear as possible look at the lining of your intestines. It is worse to have to repeat the exam if the preparation is inadequate. None of the choices would be considered ideal and many people feel the preparation is the roughest part of having a colonoscopy. There are a variety of preparations available but they all involve drinking a lot of fluid. Golytely is a big jug of liquid which now has a variety of flavors- best served chilled, which makes it a bit more tolerable. A smaller size of this approach with some pills (HalfLytely)– is available as well. A clean out with pills (Osmoprep and Visicol) is available as well but still requires you to drink a large amount of fluid. Some people may be best suited for certain preparations – depending on their medical conditions. If you had a very difficult time with one preparation, talk to your physician, as there usually are alternatives.

Often a scope is done to determine how active your disease is, so it is safe to undergo a scope if you have moderate or mild activity. Sometimes if the intestines are severely inflamed, your gastroenterologist may decide to stop the procedure early so as to minimize any risk of complications.

Question:
I have been given many medications for my Crohn's: (azathiaprine, infliximab, flagyl) Is it safe to take these medicines for longer than one year?

Dr. Korzenik:
The challenge for Crohn’s disease treatment is not only to get a flare under control but to keep someone well for a lifetime. These medications- infliximab, azathioprine, flagyl- have been studied over long periods of time. Though studies tend to be for a year, clinical experience has extended far beyond that and FDA monitors safety reports of problems which may arise. All these medications have their own set of potential complications and need to be assessed to decide if the particular risks outweigh the benefits. As with any medication, they need to be monitored for their particular potential problems. However, they all can be used safely for many years. Azathioprine and a similar medication- 6-mercaptopurine have been safely used for decades. Infliximab is newer but also can be used as maintenance medication as can flagyl.

Question:
Are generic medicines as good as the brand medicines? How does the FDA decide which drugs to approve? Why does approval take so long?

Dr. Korzenik:
Generic medications are regulated as are the brand name medications and can be safely substituted. However, it is probably best not to switch back and forth between them- particularly for a medication such as azathioprine: if you are using the generic, stay with it, if you are using the brand name – stay with that. While the medication may be identical, there may be subtle differences in concentration or availability that could influence levels of the medication.

The FDA mandates a long set of studies required before a medication can be used for a particular disease: safety testing in animals; safety testing in people and ultimately at least two large studies have to be performed to establish benefit and safety. These studies can take a long time- as they involve many people over an extended period. The FDA has been criticized for delays and inadequate oversight. The agency is currently undergoing some reorganization to try to be better and faster at approving medications with better oversight both before and after approval of a medication.

Question:
Can you have both ulcerative colitis and Crohn's disease? My doctor says I have features of both.

Dr. Korzenik:
Most people can be diagnosed as having definitely either Crohn’s disease or ulcerative colitis. However, there is a small subgroup of individuals – 5-15% in some series in which the diagnosis is difficult because the person has features of both diseases. This group of people are said to have indeterminate colitis – it could be either one, but not both. Sometimes, when followed over a longer period of time, the diagnosis can be clearer. Many of the medications we use for one can be used for the other – though some medications such as antibiotics, can be helpful in Crohn’s disease but not ulcerative colitis. The specific diagnosis can also be important if surgery is being considered as the type of surgery might be different depending on the diagnosis.

Question:
I am on Remicade as a "last resort". I understand there are more biologics waiting for FDA approval. Will they be as good as or better than Remicade? Should I switch when the new biologics are available?

Dr. Korzenik:
Fortunately, the road ahead for new medications likely to be approved for Crohn’s disease or ulcerative colitis looks good. Two medications are currently awaiting approval by the FDA for Crohn’s disease (Humira and Cimzia) and many others are currently in clinical studies for approval. Approval is expected for these two medications within the next 6 months. If you are doing well on Remicade, I would not recommend switching. If you got much better on Remicade and have lost the benefit, then it would be reasonable to switch to one of the newer medications when they are approved.

Question:
My wife has ulcerative colitis, is a few weeks pregnant and is having a flare-up. What drugs can be safely used? Will she be sick until she has the baby? Will she need a caesarian section?

Dr. Korzenik:
Most medications for ulcerative colitis can be safely used in pregnancy but your wife should discuss the question in detail with her doctor. She should be followed by a gynecologist who specializes in more complex pregnancies such as someone with IBD. The general guideline is that a healthy mother makes a healthy baby. Some people stop their medications in pregnancy, not sure if they are safe, and then flare, being off medication. The flare is more of a concern than most of the medications used so it is important to be in close contact with your doctor before and throughout pregnancy to keep or get your colitis in good control. A caesarian section is not necessary for most people with ulcerative colitis.