Wednesday, May 11, 2016

Ulcerative Colitis | Facts & Case Studies

What is Ulcerative Colitis?


Ulcerative colitis, which is the most common type of inflammatory bowel disease, is a condition of episodic inflammation of the lining, or mucosa, of the colon, resulting in bloody diarrhea. The other type of inflammatory bowel disease is Crohn’s disease.

The cause of ulcerative colitis is unknown, but both environmental and genetic factors are thought to have a role. The condition is more common in North America and Northern Europe than in other parts of the world. The risk of ulcerative colitis is increased if there is a family history of inflammatory bowel disease.

Ulcerative colitis is less common in smokers and smokers who have ulcerative colitis tend to have mild disease. Having had an appendectomy at a young age decreases the risk of developing   ulcerative colitis. The inflammation in ulcerative colitis is felt to possibly be due to an immune response against the bacteria that normally live in the colon. The inflammation usually starts at the rectum, which is the end of the colon, and it can extend in a continuous manner to involve more areas and possibly the entire colon.

If the inflammation of ulcerative colitis only involves the rectum it is called ulcerative proctitis . If the rectum and the adjacent area, which is known as the sigmoid colon, are involved, it is called proctosigmoiditis. If the inflammation is more extensive but still limited to the left side of the colon that is known as left-sided colitis. Involvement of more than the left side of the colon is referred to as pancolitis.

It is possible that over time the inflammation may spread to areas of the colon that were not involved at the time of diagnosis. Ulcerative colitis does not affect the small intestine, except for occasional involvement of the ileum, which is located adjacent to the colon.

Besides bloody diarrhea, attacks of ulcerative colitis might cause abdominal pain, weight loss, anemia, passage of mucus, and fever. Most people will have periods of relapse and remission. In addition, ulcerative colitis may have manifestations outside of the colon, possibly causing arthritis, skin and mouth lesions, inflammation of the eyes, and liver disease.




A number of medications may be used in the treatment of ulcerative colitis. The aminosalicylates, which include mesalamine, olsalazine, sulfasalazine, and balsalazide, are often the medication of choice both to achieve and to maintain remission.

Glucocorticoids may be used to achieve remission when aminosalicylates are not adequate, but are not effective in the maintenance of remission. The immunosuppressive agents azathioprine or 6-mercaptopurine might be prescribed in order to avoid the use of glucocorticoids, which can cause a number of serious side effects, including elevated glucose, osteoporosis, thinning of the skin, weight gain, cataracts, and several others.

Other medications that might be used in serious cases of ulcerative colitis include the immunosuppressive agents cyclosporine and tacrolimus, and the biologic agents, such as infliximab and adalimumab.

Up to about 30 percent of people with ulcerative colitis will ultimately require surgery, either due to failure of medical treatment or to complications. Removal of the entire colon (total colectomy) can cure the colonic manifestations of ulcerative colitis. However, total colectomy may not affect the risk or severity of ulcerative colitis associated liver disease.


Risk Factors


People with ulcerative colitis have an increased risk of colorectal cancer beginning about eight years after diagnosis, and thus periodic colonoscopy with biopsies to look for dysplasia or cancer is important. The cancer risk is related to the duration of disease and the extent of the colon involvement.


Underwriting Ulcerative Colitis


The underwriter considers a number of factors when evaluating applicants with ulcerative colitis, including current status, the extent of colon involvement, time since diagnosis, treatments prescribed, complications, and results of colonoscopy.


Case Studies


Applicant 1 was diagnosed with ulcerative colitis five years ago, with disease limited to the proctosigmoid area. No treatment has been necessary for the past three years, and a recent colonoscopy was normal. This case can be Standard Plus.

Applicant 2 has had pancolitis for fifteen years with associated arthritis, is taking azathioprine, and recently had a benign colonoscopy with biopsies. This case can be Table Three off of a Standard Plus base rate.

Applicant 3 has had ulcerative colitis for ten years. A recent colonoscopy showed three areas of dysplasia. Complete removal of the colon has been recommended, which the applicant is   considering. The dysplasia is premalignant and no offer can be made at this time. If the colon is removed reconsideration can be given based upon review of the pathology report. This case is a decline.

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Monday, April 25, 2016

Rheumatoid Arthritis | Facts & Cases


Rheumatoid arthritis is an autoimmune disease of unknown cause that results in chronic systemic inflammation affecting many parts of the body, but primarily the joints. The clinical course is highly variable. The disease can fluctuate and may sometimes go into remission for months or years, either spontaneously or with the use of various medications. After 10 years, about 20% of those affected will have no disability or joint deformities. Most however experience a progressive course with exacerbations and remissions associated with some loss of functioning. About 5-15% of affected individuals will have persistent disease activity throughout the course of this illness.


The disease process causes inflammation of the capsule around the joints, eventually leading in some cases to destruction of articular cartillage and fusion of the joints. While it usually involves smaller joints on both sides of the body, resulting in painful swelling and stiffness, it can also affect the larger joints. Likewise, in about 15-25% of cases the diffuse inflammation can involve the lungs, heart, kidneys, eyes, skin, nerves and blood vessels. About 1% of the population has rheumatoid arthritis, and women are two to three times more likely to have the disease than men. The onset can occur at any age, but it usually presents between the ages of 25 and 50. Rheumatoid arthritis becomes more prevalent at older ages.

Diagnosis & Treatments

Diagnosis is clinical and based on symptoms, physical exam, X-rays and serologic testing. There is no cure for rheumatoid arthritis, but many different treatments can improve symptoms and slow progression of the disease. Disease-modifying anti-rheumatic drugs (DMARDs) are the primary treatment. Started early in the course of the disease, these drugs produce remissions in about 50% of individuals. They generally improve symptoms, decrease joint damage and improve overall functional capacity.

Examples include methotrexate, sulfasalazine, leflunomide and hydroxychloroquine. Biologic agents may be part of the regimen. Examples include TNF blockers, interleukin 1 blockers and monoclonal antibodies. Non-steroidal anti-inflammatory agents can relieve symptoms but do not impact the course of the disease. Steroids can provide short term relief, but are generally avoided for long term use due to side effects.


Rheumatoid arthritis can reduce expectation of life by approximately 3 to 12 years. Higher mortality risk is associated with a younger age at onset, a longer duration of disease, concurrent presence of other health problems, and characteristics of more severe and progressive disease. The most common causes of death are cardiovascular disease, cancer and infection. Again, the underlying unifying pathology is generalized severe ongoing inflammation. Some of the more effective treatments for this disease may also have serious side-effects that contribute to its mortality.

Case Studies

A 62 year old woman who was diagnosed with rheumatoid arthritis about 10 years ago. She is currently working full-time and plays golf once a week. She has occasional joint discomfort that responds to ibuprofen, and has required no other treatment. This can be Standard Plus.

A 55 year old year old woman who has had rhematoid arthritis for several years. She is active in her community and participates in several volunteer organizations. She is limited by occasional diffuse joint pain and stiffness that have improved considerably with the use of methotrexate and a biologic agent. This can be Table 2.

A 58 year old man who has been unable to work for the past three years due to severely deformed joints resulting from rheumatoid arthritis that began in his early 20s. He has undergone several joint replacements as well as cervical spine surgery for instability due to rheumatic involvement. He has recently experienced increasing shortness of breath, and his physician has been unable to determine whether his lungs have been affected by rheumatoid arthritis, its treatment with methotrexate, or perhaps both. This would be a decline.