Expert Q&A

A: Hair loss can be a rare side effect of anti TNF agents like Infliximab and it is considered a class effect. If you were very ill with nutritional deficiencies and emotional stress prior to starting Infliximab, there can be hair loss during recovery which will resolve with time. This is called Telogen effluvium is a form of diffuse, nonscarring hair loss that presents as a transient or chronic loss of hair. Hair loss in telogen effluvium occurs because of an abnormal shift in follicular cycling that leads to the premature shedding of hair. Best is to consult a dermatologist, who will be able to do further investigations to find the cause and decide on treatment options including considering discontinuing of Infliximab. hide answer

A: Disease activity is related to inflammation. It is usually evaluated by endoscopy with biopsies or radiologically with CT or MRI of abdomen/pelvis. Disease activity dose not corelate well with patient symptoms in IBD. This discrepancy is more pronounced in crohn’s disease compared to ulcerative colitis. Therefore, you can be symptomatic but have inactive crohn’s disease. In other words, GI symptoms in crohn’s disease does not have to be due to active inflammation. If your disease is inactive, then adjusting crohn’s medications does not going to help with controlling your symptoms. In this situation it is important to look for other reasons such as infections, bile salt diarrhea, lactose intolerance and functional GI/IBS like symptoms. Other possibility is celiac disease as its incidence is slightly higher in IBD patients compared to general population. hide answer

A: Uveitis occurs in 0.5 to 3 percent of patients with IBD. Anterior uveitis is also called iritis. Uveitis may precede diagnosis of IBD and may be associated with arthritis. It is four times more common in females as compared with males. Prompt diagnosis and therapy with topical or systemic steroid is necessary. Secondary glaucoma and rarely blindness may occur if management is delayed. The course of uveitis usually does not parallel the activity of IBD. Therefore, I would recommend you get evaluation by an ophthalmologist as soon as possible to confirm the diagnosis. I don’t know the exact risk of glaucoma related to topical steroids but likely it is low. This may be episcleritis which occurs during flare of intestinal IBD activity. Episcleritis, inflammation of the episclera, the layer directly beneath the conjunctiva, is the most common ocular manifestation of IBD, occurring in 2 to 5 percent of patients. If that’s the case and this happens every 3-6 months, that is an indication of suboptimal control of your crohn’s disease. That means your current medication regimen needs to be adjusted to better control the disease. This may require checking the drug level if you are on a biologic or consider switching to a biologic if you are not on one. Of course, infection needs to be ruled out but less likely due to repetitive nature. hide answer

A: During acute illness and recovery menstrual cycles can be irregular or missing. This is commonly related to functional hypothalamic amenorrhea/absence of cycle due to acute illness, weight loss or nutritional deficiencies. Sometimes resolution of acute illness, correction of nutritional deficiencies or gaining the weight do not correct the menstrual cycle irregularity. Did you lose > 10% of your body weight due to keto diet, which may be the reason for absent menstrual cycle. Pregnancy needs to be ruled out and should also look for other causes like thyroid dysfunction or celiac disease. If these are absent recommend discussing with your PCP and gyn. hide answer

A: You are taking Entocort 3 mg pills, which the effective form of budesonide for microscopic colitis (lymphocytic colitis and collagenous colitis). Uceris is the formula that is mainly released in colon and it comes as 9 mg pill. Entocort is a locally active corticosteroid that has been used in patients with microscopic colitis, a study in 2018 confirmed its efficacy compared to placebo in lymphocytic colitis. As Entocort is locally acting and its systemic side effects are less than other oral corticosteroids like prednisone. This is due to its extensive breakdown in liver resulting decrease systemic exposure. Therefore, this is the safer form steroid. Although there is symptomatic improvement in symptoms with few days of therapy complete resolution needs at least 6- 8 weeks of Entocort 9 mg daily followed by taper over 1 month. If there is relapse of symptoms during taper, 9 mg daily treatment can be extended into 12 weeks or longer before tapering. Your treatment recommendation is the standard of care. We need to also make sure to eliminate triggers such as smoking and NSAIDs use as well as infection, celiac disease, hyperthyroidism, etc. Even after elimination of other causes and triggers, about 10-20% of patients may not respond to Entocort. In these patients it may be necessary to use immunomodulators like azathioprine or biologics such as anti TNF agents (Infliximab, Adalilumab, etc) hide answer