Edward V. Loftus Jr., MD, AGAF

 

Uma Mahadevan, MD, AGAF, and I moderated this session on IBD, and we were fortunate enough to secure four of the best IBD educators in the AGA.

David Rubin, MD, AGAF, opened with “Selecting the correct therapy for your outpatients with IBD: From mesalamine to biologics.” Treatment goals have evolved from symptom control to remission based on measures of inflammation (e.g., serum C-reactive protein, fecal calprotectin, or endoscopy). For ulcerative colitis (UC), high-risk markers include extensive disease, deep ulcers, younger age at diagnosis, elevated biomarkers, and early need for steroids or hospitalization. For Crohn’s disease (CD), these include younger age, extensive involvement, and fistulizing disease. The 5-aminosalicylate drugs remain a backbone in mild to moderate UC. Judicious use of corticosteroids is reasonable, but we need an exit strategy. The thiopurines are decent drugs, but studies have called into question their efficacy as monotherapy, and safety issues persist. Methotrexate is underutilized. The anti–tumor necrosis factor (TNF) biologics are excellent therapies but controversies persist as to whether these drugs require combination therapy or if they can be managed as “optimized monotherapy” with therapeutic drug monitoring (TDM). There are now two infliximab biosimilars available in the U.S.. Vedolizumab is an efficacious gut-selective anti-integrin (for both CD and UC). Ustekinumab, an anti-IL-12/23 antibody, is now available for moderate to severe CD, and has a favorable safety profile.

William Sandborn, MD, AGAF, discussed “Severe ulcerative colitis in the hospitalized patient.” Severe UC is characterized by at least six bowel movements daily, blood in the stool, fever, tachycardia, anemia, and elevated ESR. Other predictors of severity include colonic dilation, deep ulcers, and lack of response to 3 days of IV corticosteroids (e.g., stool frequency more than 8/day or CRP more than 45 mg/L). About 70% of patients will respond to IV steroids; for those who don’t, options include IV cyclosporine or IV infliximab. These drugs are equivalent in efficacy; however, cyclosporine toxicity can include serious or fatal infections in up to 3% of patients. The challenge with infliximab is pharmacokinetics – many severely ill patients will have protein-losing colopathy, detectable fecal infliximab levels, and lower serum levels resulting in lack of response – so early dose escalation may be required. A day-by-day algorithm for managing severe UC in the hospital was reviewed (see Clin Gastroenterol Hepatol. 2012;10:1315-25).

Fernando Velayos, MD, AGAF, discussed “Surveillance for dysplasia: What is the standard of care in 2017?” General principles for surveillance colonoscopy in IBD include having quiescent disease, since inflammation can reduce ability to detect lesions, and good colonic preparation. The three U.S. society guidelines recommend starting surveillance after 8 years of disease. Patients with concomitant primary schlerosing cholangitis should begin surveillance immediately. Frequency of surveillance ranges every 1-3 years depending on histology. A meta-analysis showed a higher incremental dysplasia yield with chromoendoscopy compared to standard white-light colonoscopy. If visible dysplasia can be endoscopically resected, then continued surveillance rather than colectomy is recommended.

Sunanda Kane, MD, AGAF, discussed “Managing special populations: the transitioning adolescent, the gravid, and the elderly.” The transition from pediatric to adult IBD care is a high-risk time because the patient may be lost to follow-up or not adhere to the medical regimen, resulting in increased risk of flare. Successful transition requires developmental maturity of the patient, a certain style of parental involvement, and care coordination of the medical team. For women with IBD considering pregnancy, active IBD at the time of conception significantly increases the risk of flare. Women with CD who have no history of perianal disease don’t have an increased risk of perianal disease with vaginal delivery. A meta-analysis of the risk of congenital malformations with thiopurines found no significant association. Infliximab levels were likely to rise in the mother during the second and third trimesters (versus no increase with adalimumab), so one could consider TDM to guide dosing. In the PIANO study, anti-TNF therapy in the third trimester was neither associated with adverse pregnancy outcomes nor with infections up to 1 year for children. Patients who develop IBD later in life are more likely to have colonic inflammation. Elderly UC patients are more likely to require surgery, and postop mortality is higher for both CD and UC.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017. Dr. Loftus is a professor of medicine, division of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn.

 

Uma Mahadevan, MD, AGAF, and I moderated this session on IBD, and we were fortunate enough to secure four of the best IBD educators in the AGA.

David Rubin, MD, AGAF, opened with “Selecting the correct therapy for your outpatients with IBD: From mesalamine to biologics.” Treatment goals have evolved from symptom control to remission based on measures of inflammation (e.g., serum C-reactive protein, fecal calprotectin, or endoscopy). For ulcerative colitis (UC), high-risk markers include extensive disease, deep ulcers, younger age at diagnosis, elevated biomarkers, and early need for steroids or hospitalization. For Crohn’s disease (CD), these include younger age, extensive involvement, and fistulizing disease. The 5-aminosalicylate drugs remain a backbone in mild to moderate UC. Judicious use of corticosteroids is reasonable, but we need an exit strategy. The thiopurines are decent drugs, but studies have called into question their efficacy as monotherapy, and safety issues persist. Methotrexate is underutilized. The anti–tumor necrosis factor (TNF) biologics are excellent therapies but controversies persist as to whether these drugs require combination therapy or if they can be managed as “optimized monotherapy” with therapeutic drug monitoring (TDM). There are now two infliximab biosimilars available in the U.S.. Vedolizumab is an efficacious gut-selective anti-integrin (for both CD and UC). Ustekinumab, an anti-IL-12/23 antibody, is now available for moderate to severe CD, and has a favorable safety profile.

William Sandborn, MD, AGAF, discussed “Severe ulcerative colitis in the hospitalized patient.” Severe UC is characterized by at least six bowel movements daily, blood in the stool, fever, tachycardia, anemia, and elevated ESR. Other predictors of severity include colonic dilation, deep ulcers, and lack of response to 3 days of IV corticosteroids (e.g., stool frequency more than 8/day or CRP more than 45 mg/L). About 70% of patients will respond to IV steroids; for those who don’t, options include IV cyclosporine or IV infliximab. These drugs are equivalent in efficacy; however, cyclosporine toxicity can include serious or fatal infections in up to 3% of patients. The challenge with infliximab is pharmacokinetics – many severely ill patients will have protein-losing colopathy, detectable fecal infliximab levels, and lower serum levels resulting in lack of response – so early dose escalation may be required. A day-by-day algorithm for managing severe UC in the hospital was reviewed (see Clin Gastroenterol Hepatol. 2012;10:1315-25).

Fernando Velayos, MD, AGAF, discussed “Surveillance for dysplasia: What is the standard of care in 2017?” General principles for surveillance colonoscopy in IBD include having quiescent disease, since inflammation can reduce ability to detect lesions, and good colonic preparation. The three U.S. society guidelines recommend starting surveillance after 8 years of disease. Patients with concomitant primary schlerosing cholangitis should begin surveillance immediately. Frequency of surveillance ranges every 1-3 years depending on histology. A meta-analysis showed a higher incremental dysplasia yield with chromoendoscopy compared to standard white-light colonoscopy. If visible dysplasia can be endoscopically resected, then continued surveillance rather than colectomy is recommended.

Sunanda Kane, MD, AGAF, discussed “Managing special populations: the transitioning adolescent, the gravid, and the elderly.” The transition from pediatric to adult IBD care is a high-risk time because the patient may be lost to follow-up or not adhere to the medical regimen, resulting in increased risk of flare. Successful transition requires developmental maturity of the patient, a certain style of parental involvement, and care coordination of the medical team. For women with IBD considering pregnancy, active IBD at the time of conception significantly increases the risk of flare. Women with CD who have no history of perianal disease don’t have an increased risk of perianal disease with vaginal delivery. A meta-analysis of the risk of congenital malformations with thiopurines found no significant association. Infliximab levels were likely to rise in the mother during the second and third trimesters (versus no increase with adalimumab), so one could consider TDM to guide dosing. In the PIANO study, anti-TNF therapy in the third trimester was neither associated with adverse pregnancy outcomes nor with infections up to 1 year for children. Patients who develop IBD later in life are more likely to have colonic inflammation. Elderly UC patients are more likely to require surgery, and postop mortality is higher for both CD and UC.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017. Dr. Loftus is a professor of medicine, division of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn.

 

Uma Mahadevan, MD, AGAF, and I moderated this session on IBD, and we were fortunate enough to secure four of the best IBD educators in the AGA.

David Rubin, MD, AGAF, opened with “Selecting the correct therapy for your outpatients with IBD: From mesalamine to biologics.” Treatment goals have evolved from symptom control to remission based on measures of inflammation (e.g., serum C-reactive protein, fecal calprotectin, or endoscopy). For ulcerative colitis (UC), high-risk markers include extensive disease, deep ulcers, younger age at diagnosis, elevated biomarkers, and early need for steroids or hospitalization. For Crohn’s disease (CD), these include younger age, extensive involvement, and fistulizing disease. The 5-aminosalicylate drugs remain a backbone in mild to moderate UC. Judicious use of corticosteroids is reasonable, but we need an exit strategy. The thiopurines are decent drugs, but studies have called into question their efficacy as monotherapy, and safety issues persist. Methotrexate is underutilized. The anti–tumor necrosis factor (TNF) biologics are excellent therapies but controversies persist as to whether these drugs require combination therapy or if they can be managed as “optimized monotherapy” with therapeutic drug monitoring (TDM). There are now two infliximab biosimilars available in the U.S.. Vedolizumab is an efficacious gut-selective anti-integrin (for both CD and UC). Ustekinumab, an anti-IL-12/23 antibody, is now available for moderate to severe CD, and has a favorable safety profile.

William Sandborn, MD, AGAF, discussed “Severe ulcerative colitis in the hospitalized patient.” Severe UC is characterized by at least six bowel movements daily, blood in the stool, fever, tachycardia, anemia, and elevated ESR. Other predictors of severity include colonic dilation, deep ulcers, and lack of response to 3 days of IV corticosteroids (e.g., stool frequency more than 8/day or CRP more than 45 mg/L). About 70% of patients will respond to IV steroids; for those who don’t, options include IV cyclosporine or IV infliximab. These drugs are equivalent in efficacy; however, cyclosporine toxicity can include serious or fatal infections in up to 3% of patients. The challenge with infliximab is pharmacokinetics – many severely ill patients will have protein-losing colopathy, detectable fecal infliximab levels, and lower serum levels resulting in lack of response – so early dose escalation may be required. A day-by-day algorithm for managing severe UC in the hospital was reviewed (see Clin Gastroenterol Hepatol. 2012;10:1315-25).

Fernando Velayos, MD, AGAF, discussed “Surveillance for dysplasia: What is the standard of care in 2017?” General principles for surveillance colonoscopy in IBD include having quiescent disease, since inflammation can reduce ability to detect lesions, and good colonic preparation. The three U.S. society guidelines recommend starting surveillance after 8 years of disease. Patients with concomitant primary schlerosing cholangitis should begin surveillance immediately. Frequency of surveillance ranges every 1-3 years depending on histology. A meta-analysis showed a higher incremental dysplasia yield with chromoendoscopy compared to standard white-light colonoscopy. If visible dysplasia can be endoscopically resected, then continued surveillance rather than colectomy is recommended.

Sunanda Kane, MD, AGAF, discussed “Managing special populations: the transitioning adolescent, the gravid, and the elderly.” The transition from pediatric to adult IBD care is a high-risk time because the patient may be lost to follow-up or not adhere to the medical regimen, resulting in increased risk of flare. Successful transition requires developmental maturity of the patient, a certain style of parental involvement, and care coordination of the medical team. For women with IBD considering pregnancy, active IBD at the time of conception significantly increases the risk of flare. Women with CD who have no history of perianal disease don’t have an increased risk of perianal disease with vaginal delivery. A meta-analysis of the risk of congenital malformations with thiopurines found no significant association. Infliximab levels were likely to rise in the mother during the second and third trimesters (versus no increase with adalimumab), so one could consider TDM to guide dosing. In the PIANO study, anti-TNF therapy in the third trimester was neither associated with adverse pregnancy outcomes nor with infections up to 1 year for children. Patients who develop IBD later in life are more likely to have colonic inflammation. Elderly UC patients are more likely to require surgery, and postop mortality is higher for both CD and UC.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017. Dr. Loftus is a professor of medicine, division of gastroenterology and hepatology, Mayo Clinic, Rochester, Minn.