- Do
you have a treatment guideline in Sweden? If
so, would you please explain what it is and
how it works? What kind of drugs or medical
treatment do you offer UC and CD patients?
There is a general guideline (pyramid
system; fig, 1) but perhaps not as organized
as that in Japan. We start to treat patients
in Sweden with the mildest type of medications
like 5-ASA (Asacol, Dipentum), or Salazopyrin
for UC, and metronidazole (Flagyl) or budesonide
(Entecort, a topical steroid) for CD. 5-ASA
is not used much for CD in Sweden because there
is little evidence that it works in CD. Then
there is prednisolone for moderately active
UC and CD. If that does not work, then we use
the immunomodulators (IMM) like azathioprine
(AZ) or 6-mercaptopurine (6-MP). If that fails,
we sometimes use Infliximab (Remicade) but only
for CD. However, Infliximab may be associated
with serious side effects like opportunistic
infections, sometimes lethal. At the same level,
we have the Adacolumn for UC. Unlike Japan,
we never use cyclosporine A (CyA) in Sweden
because it is associated with many long-term
problems and ultimately, patients treated with
CyA usually will have a colectomy anyhow. For
maintenance therapy, we use 5-ASA or sulfasalazine
for UC and, AZ or 6-MP for CD. AZ has become
a drug of choice for CD, and if treated optimally
with AZ, many CD patients can avoid Infliximab.
So we always start with AZ before going to Infliximab.
Moreover, in Scandinavia at least, there is
no increase in mortality in IBD patients compared
to the general population, so we must be very
careful with using potentially toxic drugs which
could induce serious adverse events including
for example, severe infections and lymphoma
in these patients.
- Which
medicine is used for outpatient treatment?
In general, fewer and fewer patients are treated
as in-patients. Most IBD patients are treated
as out-patients in Daycare units or IBD out-patient
units. Only IBD patients with a severe attack
of disease or in need of surgery are treated
as in-patients. IBD patients visit their doctors
about once every 4 weeks during active disease
stage, while during inactive stage, they visit
their doctors about 1-2/year.
- Do
you give elemental diet in Sweden?
We rarely use elemental diet (ED) in Sweden.
ED is more of a supplement for some patients.
It is also used as a pre-operative diet, especially
total parenteral nutrition (TPN). TPN given
intravenously is more commonly used pre-operatively
compared to enteral diet.
- How
is extracorporeal apheresis system used in Sweden?
We have just started the Adacolumn in Sweden.
We are the first to use the Adacolumn in a broad
scale outside Japan. It has just been introduced
in Sweden. The results are very promising.
- Please
tell me about surgery for UC and CD patients
in Sweden? When do you think surgery is suitable?
I
think we are liberal with surgery in Sweden.
If a patient has chronic active disease, we
would rather opt for surgery rather than toxic
drugs. In UC, we have the pelvic pouch type
of operation (ileoanal anastomosis) which is
a good alternative in chronic active disease
or severe colitis. The procedure was first performed
in Sweden in 1980, so we have 22 years of experience.
We also perform surgery early for CD patients,
by making small directed resections because
patients are doing well (could be well for up
to 10 years without medications) after this
small resection procedure. However, there is
a need for close collaboration between the gastroenterologists
and surgeons all the time to decide the best
option for the particular patients. The number
of colectomy is decreasing; fewer and fewer
patients are undergoing major operation such
as colectomy these days.
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Circumstances
of CD and UC patients 
General Information 
Interview
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