Inflammatory Bowel Disease

Thank you to Dr Ehrlich for a very insightful lecture on Inflammatory Bowel Disease (IBD)!

Click here for the lecture powerpoint!

See Lecture Video Database for the lecture recording (coming soon).

Epidemiology

  • 1.4 million people in US
  • Urban population
  • Northern climates
  • Bimodal age incidence distribution
    • 15-30 yo
    • 50-65 yo
  • No known dietary triggers. So for the most part patients can eat whatever they want.

Disease Characteristics

  • See powerpoint Slide #5 for table describing differences between UC and Crohn’s.
  • Note: Patients are at increased risk of cancer due to chronic inflammation

Medications for Ulcerative Colitis (UC)

Topical Medications

  • 5asa suppository or enema
  • Steroid suppository, foam, enema

Oral Medications

  • 5-ASA
  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Cyclosporine (rarely used anymore)
  • Methotrexate
  • Biologics (Anti TNF alpha inhibitors):
    • Infliximab (IV infusion)
    • Adalimumab (SC injection)
    • Golimumab: similar to the other drugs on the market
  • Budesonide MMX: newer agent; tablet that only gets released when it hits the colon. For mild to moderate UC. Use as an adjunct to 5asa to get pt back in remission

Treatment Strategy:

  • Combination oral and topical initially. Then just oral when it’s better controlled
    Avoid steroids if possible

Medications for Crohn’s Disease

Topical Medications

  • Only useful in Crohn’s Colitis.

Oral Medications

  • Immunomodukators (6mp, azathioprine)
  • Steroids
  • Antibiotics
  • Methotrexate as adjunct
  • Biologics (anti TNF alpha: Infliximab (IV infusion),  Adalimumab (SC injection)
  • Natalizumab: causes pml so not used anymore
  • Vedolizumab: antibiotics integrin prevents leukocyte tracking. Similar to natalizumab, but specific to the gut. No PML so far. IV on weeks 0, 2, 6 and every 8 weeks thereafter
  • More effective in UC compared to crohn’s
  • Ustekinumab (Stelara) il 23 inhibitor, previously approved for psoriasis. Note at a higher dose for crohn’s.
  • Check out the Uniti1 and Uniti2 Trials for more information

Health Maintenance in IBD Patients

Vaccines in Immunosuppressed Patients

As is inherent in the term, the immune response is blunted with immunosuppressives and thus live vaccines are contraindicated.  BUT, there is no evidence that giving a vaccine will cause an IBD flare.

Definition of immunosuppression:

  • Prednisone 20mg daily for two or more weeks and within three months of discontinuation
  • Treatment with immunomodulators or biologics and within three months of discontinuation
  • Significant protein/calorie malnurition

And other vaccines are contraindicated in immunosuppressives

Inactivated vaccines are able to be given in immunosuppression:

  • Ex: TDaP, HPV, Influenza, Hepatitis A, Hepatitis B, Pneumococcal

Live vaccines should NOT be given in immunosuppression:

  • Ex: Varicella, Herpes Zoster, MMR

Bone Health in IBD

Assess bone density (via DEXA) in the following conditions:

  • Total steroid use >3 months
  • Inactive disease but past chronic steroid use of at least 1 year but within the last 2 years
  • Inactive disease but maternal history of osteoporosis
  • Inactive disease but malnourished or very thin
  • Inactive disease but amenorrheic
  • Post menopausal women regardless of disease status

Skin exam yearly if on immunosuppressed

Colonoscopy and Cancer Screening in IBD

  • IBD with greater than 1/3 of colon affected? If yes, then start colon cancer screening 8 to 10 years after initial diagnosis. Then, screen every 1-2 years.
    • Chromoendoscopy preferred
  • Tobacco cessation
    Depression screening

Tidbits on Medications

  • 5-ASA: commonly causes renal insufficiency (check once yearly Cr)
  • Immunomodulators (AZA, 6MP, MTX): monitor for blood and liver abnormalities;  cancer(lymphoma), pancreatitis
    • Check these tests weekly for a monthly then space out
  • Anti-TNF alpha: Check HBV and TB before initiation

IBD during Pregnancy

  • MTX absolutely contraindicated
  • Sulfasalazine causes reversible azoospermia in men
  • Key Point: Keep sxs controlled. Most meds can be continued during pregnancy

Chief’s Case 10-11-16

First Chief’s case of the season is over and done.  The focus was on clinical reasoning and going through the steps of creating an appropriate problem representation, that leads to a differential diagnosis, which then triggers illness scripts.

Clinical Reasoning Tips to take away:

  1. Problem Representation-  Create an effective “1-liner” about the patient and their story
    1. Salient features- i.e. fever, rash, lab abnormalities
    2. Temporal relation of conditions
    3. Syndrome
  2. Illness Scripts- mental summary of a provider’s knowledge of a disease
    1. Predisposing conditions
    2. Pathophysiological insult
    3. Clinical consequences

Example from Chief’s Case (Malaria):

Problem Representation:

  • 29 year old pregnant female, recently traveled to Sudan, presents with ~1 week of fever, shortness of breath, epigastric pain, found to have elevated total bilirubin, metabolic acidosis, anemia and thrombocytopenia.

Illness Script:

  • Malaria
    • Pathophysiology- plasmodium infection, transmitted by mosquitos, going to liver and then invading RBCs
    • Epidemiology- endemic areas (Sub-Saharan Africa and Southeast Asia), increased infection for young children, immunocompromised, pregnant women.
    • Time Course- days to weeks, can lie dormant (P. vivax or P. ovale) for months in liver
    • Salient symptoms/signs- fever, chills, nausea/vomiting/diarrhea, abdominal pain, tachycardia, tachypnea, headache
    • Diagnostics- anemia, thrombocytopenia, LFT abnormalities, U/S with hepatosplenomegaly.  Thick/thin smear (x3 to completely rule out).
    • Treatment- depends on resistance pattern and pregnancy status.  Will need definitive treatment for dormant liver parasites.

Thank you for the expert opinion from Drs. Dan Mueller and Bizath Taqui!

Time Management

Time management refers to the way you organize and plan how long you spend on specific activities.

Time management is a bit of a misnomer.  Really it is about managing your overall workload and productivity.

Trying to multi-task will cause you to be inefficient because you are constantly switching between different tasks.  The act of switching between tasks costs time and makes you less productive.  It will also lead to cognitive errors and fatigue.

Studies show people are more productive with short bursts of activity that last about 90 minutes followed by a break.

Practical Tips:

  • Minimize Multi-Tasking
  • Check email/Epic only once a day
  • Minimize interruptions
  • List your goals and organize/group the activities
    • Core responsibilities-admitting patients, phone calls to patients, etc
    • Personal Growth- projects, research, etc
    • Managing People- working with others
    • Urgent matters- crisis
    • Free Time
    • Administrative tasks

Grand Rounds-9/7/16

“Increasing Family Resilience To Improve Patient Outcomes”.

Presenter: Dr. Barry Jacobs.  Crozer-Keystone Family Medicine Residency

Link to presentation

  • Why Family Matters
    • Rapidly aging population (20% over 65 by 2030)
    • Rising incidence of chronic illnesses, functional limitations
    • Decreased hospital lengths of stay and emphasis on preventing bounce-backs
  • Family Caregiving in America
    • 43 million Americans engage in some form of caregiving activity
    • Heterogenous group.  E.g. 1/4 are Millenials (20s), 1/4 are Generation X-ers (30s)
    • 33% reported no strain, 49% some strain, 18% a lot of strain
  • Negative Effects
    • Dementia caregiving linked to 63% increased mortality, insomnia, depression, musculoskeletal, decreased use of preventative medical services
  • Positive Effects
    • Caregivers report personal and spiritual growth
  • Caregiver Intervention
    • Research from NYU Caregiver Intervention shows that it can forestall nursing home placement of Alzheimer’s patient for nearly 2 years
  • Elements of support programs
    • Frequent contact with multiple means (in-person, telephone, internet, etc)
    • Counseling
    • Acknowledgement
      • Identification of the caregiver in the patient’s chart
    • Communication
      • Ability to share observations, ask questions
    • Decision-making power
      • Include patient and family goals in care plans
    • Money
      • Payment incentives for healthcare providers to support faily caregivers
    • Assessment
      • Asking if the caregiver is willing and able to perform the tasks
    • Care management
      • Will need additional help when a patient is being transitioned from one care to another
    • Training and support
      • Better preparing the caregiver for complex medical tasks
    • Technology

Smoking Cessation

Stats:

480,000 Premature deaths per year with 3-5 times increase in all-cause mortality in smokers vs non-smokers

$289 billion in extra costs

17.8% of adults smoke

Quitting smoking before 40 years old reduced smoking-related mortality by 90%.

Cancer patients who quit at time of diagnosis reduce their risk of dying by 30-40%

 

Nicotine and addiction:

Physiologic withdrawal can last for 6 weeks

The physicians role- Ask, Advise, Assess (motivational interviewing), Assist (behavioral therapies, nicotine replacement, pharmacologic therapies), Arrange (bringing the patient back)