TREATMENT OF INPATIENTS WITH ACUTE SEVERE ULCERATIVE COLITIS

Transcription

1 TREATMENT OF INPATIENTS WITH ACUTE SEVERE ULCERATIVE COLITIS Target Audience: Physicians, Physician Assistants, Nurse Practitioners and Nurses impacted by the protocol. Scope/Patient Population: All adult inpatients admitted for treatment of moderate to severe ulcerative colitis Rationale: Ulcerative colitis is chronic disease with long periods of asymptomatic remission and intermittent exacerbations that may require acute care hospitalization. Management of acute severe ulcerative colitis is clinically challenging with a mortality rate of 1-2%. 15% of patients with Ulcerative Colitis will have an acute episode at some point during their disease course requiring hospitalization and 20% of first attacks of UC are acute in nature 1. The colectomy rate after 10 years was 9.8% 7. A treatment algorithm aids clinicians in more effectively diagnosing and treating this disease by assuring that inpatients are completely assessed upon admission, symptoms are adequately monitored and treatments are escalated to more aggressive regimens or surgery at the appropriate intervals. Objective 1. Improve the quality of patient care by treating inpatients with ulcerative colitis with the most appropriate evidence-based treatments 2. Decrease prolonged length of stay by changing course of therapy at the appropriate time intervals 3. Reduce readmissions by setting the patient up with specialized outpatient care within a shorter timeframe 4. Increase patient satisfaction by alleviating their symptoms more quickly, reducing length and frequency of hospitalization and linking them to appropriate care in the outpatient setting 5. Avoid colectomy while preventing complications, side effects of medications and mortality Page 1 of 5

2 Recommendations: Timeframe Approach Rationale Initial Work-up Lab Evaluation CBC CMP Albumin CRP Sed Rate Quantiferon Gold Documentation of chronic hep panel within past year If acute onset of diarrhea CDiff Stool cultures Lactoferrin Abdominal Flat plate CT (if concern for perforation of megacolon) Request GI Consult All patients admitted with severe UC require appropriate investigations to confirm the diagnosis and exclude enteric infection. 2 Patients with acute UC with a coexisting C. difficile infection have an increased colectomy rate and worse long-term clinical outcome and should be treated with metronidazole or vancomycin 1 Ruling out megacolon and need for surgery Ruling out megacolon and need for surgery 0-72 hours Treatment with IV Steroids Chart disease activity daily using Truelove and Witts criteria Solumedrol IV 30 mg q 12 hrs May continue 5ASA if eating If moderate severity, Two thirds of patients respond to IV steroids in the shortterm 1 Consistent, effective method for evaluating severity of disease 4 Clinical response to steroids can be assessed on day 3. The introduction of steroids for the management of acute severe UC has dramatically reduced mortality from more than 50% to 1-2%. 1 Staying on this medication may provide some benefit to the patient but patients cannot tolerate it if they are not eating. 6 To treat inflammation topically Page 2 of 5

3 If unsuccessful after 3 day of IV Steroids consider Cortenema if they can be retained and tolderated especially if left sided disease DVT/PE prophylaxis for all patients; unfractionated or low moledular weight heparin If fever > 101 and/or leukocytosis: consider IV Cipro or flagyl Labs daily: CBC, CMP If not fulminant, okay to feed low fiber, non-dairy diet If fulminant and evidence of malnutrition (albumin <2.4) consider TPN Flex-sig if not done during current flare-up Treatment with Infliximab at 5 mg/kg Notes - Only a gastroenterologist can order) - TB assessment must be completed prior to first infusion - Chronic hep panel must be completed prior to first infusion for added benefit and reduction of symptoms. Rates of VTE in hospitalized patients with Inflammatory Bowel Disease (IBD) is two to three times higher than hospitalized patients without IBD 3 Recommend IV ABX (i.e. Cipro and metronidazole) in patients with severe colitis and high grade fever, leukocytosis with extreme numbers of immature neutrophils (band form count greater than 700/micorL), and peritoneal signs or megacolon. There is no role of ABX in patients with severe colitis without signs of systemic toxicity. 6 Standard labs to monitor for disease process. Low fiber diet to rest the bowel and dairy can cause diarrhea. To maintain adequate nutrition. To confirm diagnosis and rule out CMV infection. If there is no improvement on IV steroids after three days then other medical and surgical options should be considered. If there is a partial response then IV steroids may be continued a couple days longer. 1 Patients who remain on ineffective medical therapy including corticosteroids suffer a high morbidity associated with delayed surgery. 2 Compared with treatment with only a biologic agent, Page 3 of 5

4 After 3-5 days after initiation of Infliximab, re-evaluate Discharge Evidence: Surgery Consult If not improving options: Cyclosporin Increase Infliximab to 10 mg/kg Surgery Patient should be scheduled for an outpatient visit with gastroenterology within 2-3 days. Goal is to have appointment scheduled before patient leaves hospital. corticosteroid therapy is associated with a nearly 5-fold increase in risk for VTE. 3 Data to suggest change of treatment if no response. Some patients show benefit from switching to cyclosporine if not improving on Infliximab. 1 Transition quickly to treatment in the outpatient setting to avoid readmissions 1. Hart AL, Ng SC. Review Article: The Optimal Medical Management of Acute Severe Ulcerative Colitis. Ailment Pharmacol Ther 2010 Sept;32(5): Travis SPL, Stange EF, Lemann M, Oresland T, Bemelman WA, Chowers Y, Colombel JF, D Haens G, Ghosh S, Marteau P, Kruis W, Mortenson NJMcC, Penninckx F, Gassull M. European evidence-based consensus on the management of ulcerative colitis: current management. Journal of Crohn s and Colitis Mar; 2(1): Higgins PD, Skup M, Mulani PM, Lin J, Chao J. Increased risk of venous thromboembolic events with corticosteroid vs biologic therapy for inflammatory bowel disease. C.in Gastroenterol Hepatol Feb; 13(2): Truelove S C, Witts L. Cortisone in ulcerative colitis: final report on a therapeutic trial. BMJ. 1955;2: Hurst RD, Michelassi F. ACS Surgery: Principles and Practice. Section 5: Gastrointestinal Tract and Abdomen. Chapter 13: Fulminant Ulcerative Colitis Peppercorn MA, Farrell RJ. Management of Severe Ulcerative Colitis. Wolters Kluwer Health Reprint from 7. Kappelman MD, Rifas-Shiman SL, Kleinman K, Ollendorf D, Bousvaros A, Grand RJ, Finkelstein JA. The prevalence and geographic distribution of Crohn's disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol. 2007; 5: Page 4 of 5

5 List of Implementation Items and Patient Education: TBD Metrics Plan: Reduce prolonged length of stay (define 10 days?) to X (target) by X (date) Reduce readmissions rates to X (target) by X (date) Frequency of colectomy? PDCA Plan: Review annually by the Surgery Collaborative. Point of Contact: Surgery Collaborative (Chair of Surgery Collaborative) Approval By: Collaborative (Surgery) Anesthesia Committee MHS MCC/Collaborative Leadership Original Date: Revision Dates: Reviewed with no Changes Dates: Date of Approval: 04/ / / /2016 X/XX; X/XX X/XX; X/XX Distribution: MultiCare Connected Care + MultiCare Health System Page 5 of 5