Drug transfer to the fetus and to the breastfeeding infant: what do we know?

The pregnant patient with inflammatory bowel disease presents a number of challenges to the clinician. In addition to the management of the patient's disease activity and the potential effects of disease on pregnancy, the clinician must also take into consideration any iatrogenic complications that may arise from the medical management of these conditions. Furthermore, should the patient elect to breastfeed her infant, the effect of drugs that may be passed through the breast milk must also be considered. This article focuses specifically on the issues of drug transfer to the fetus and to the breastfeeding infant. Meperidine is the sedative of choice for endoscopic procedures on pregnant patients, while benzodiazepines and propofol may be used with certain caveats. Amoxicillin/clavulanic acid and metronidazole are preferred if antibiotics are indicated for perianal Crohn's disease or pouchitis. The majority of medications used in the treatment of luminal IBD in pregnancy are not associated with significant adverse effects, and thus can generally be used safely. Certain medications, such as aminosalicylates, corticosteroids, and cyclosporine, appear low risk, while others such as methotrexate and thalidomide are clearly contraindicated. The role of other immunomodulators and biologics remains to be clearly defined, although early experience with infliximab and similar agents appear to be low risk. Safety in breastfeeding varies considerably among medications. There are many issues to address when considering pharmaceutical intervention in the pregnant patient, and patients should be carefully counseled regarding potential teratogenicity or adverse outcomes of medication used during pregnancy and breastfeeding.

Optimizing use of 5-ASA in the treatment of ulcerative colitis: Focus on patient compliance and adherence.

Ulcerative colitis is a chronic condition that requires long-term treatment. The first-line therapy remains 5-ASA, which is available in a variety of different formulations and dosing schedules. Multiple studies have demonstrated that adherence rates to prescribed 5-ASA products is below what would have been expected with significant consequences for important outcomes. Worse disease outcomes, higher medical costs, and even potentially higher rates of colorectal cancer have been associated with nonadherence. Nonadherence is multifactorial, fluid in nature over time, and dependent on disease activity level. Interventions to improve adherence rates have to be individualized. With the advent of simpler dosing regimens it was assumed that adherence rates would improve, but this has not necessarily been the case. Despite our current knowledge about nonadherence, it remains difficult to manage in the long term.

Insight into the widespread problem of nonadherence to therapy in ulcerative colitis patients.

Ulcerative colitis is a chronic condition that requires long-term treatment. The first-line therapy remains 5-aminosalicylic acid, which is available in several different formulations and dosing schedules. Several studies have demonstrated that adherence rates to prescribed 5-aminosalicylic acid products are below those expected for a drug that has significant consequences on important outcomes. Worse disease outcomes, higher medical costs and even potentially higher rates of colorectal cancer have been associated with nonadherence. Nonadherence is multifactorial, fluid in nature over time and is dependent on disease activity level. Interventions to improve adherence rates have to be individualized. With the advent of simpler dosing regimens it was assumed that adherence rates would improve, but this has not been the case. Despite our current knowledge about nonadherence, it remains difficult to manage long term.