INFLAMMATORY BOWEL DISEASE 101: From Hurdling New Diagnosis to Optimizing Treatments

Transcription

1 INFLAMMATORY BOWEL DISEASE 101: From Hurdling New Diagnosis to Optimizing Treatments Phillip Minar, MD, MS Pediatric Gastroenterologist Cincinnati Children s Hospital Medical Center

2 Objectives of Session What is IBD Crohn s disease vs. ulcerative colitis Treatment options Living with IBD Diets, supplements and school Research, outreach Optimize treatment response Drug levels Ask your questions, please interrupt!

3 Your IBD Team A Collaborative Effort to Improve Care IBD patients seen 2 nd opinion

4 IBD may interrupt, but it doesn t hold me back Mike McCready Pearl Jam Kathleen Baker Silver & Gold Medal 2016 Pete Davidson SNL Cast Larry Nance Jr NBA Player

5 How common is IBD? million people with IBD in US ~100,000 <18 years old children diagnosed each year with IBD at Cincinnati Children s >800 IBD patients at Cincinnati Children s Genetics 1 st degree relative (3-20x than general pop. to develop IBD) Identical twin Crohn s -1 in 2-3 lifetime risk UC 1 in 5 lifetime risk Both parents with IBD Child has 1 in 3 lifetime risk Prevalence: /100,000 (total living with IBD) Incidence: 3-14/100,000 (new diagnosis each year) Seating capacity ~65,000 Prevalence: (total living with IBD) Incidence: 3-14 (new diagnosis this year)

6 What is IBD? Inflammatory bowel disease (IBD) 25% 70% ~5% Ulcerative Colitis Mixed features: Indeterminate colitis Crohn s disease

7 Cause of IBD >200 Genes Loss of : 1. Protective barrier function of lining 2. Bacterial killing 3. Immune regulation Environment (Microbiome) IBD Improper Immune response Immune system attacks healthy cells of the gut, causing inflammation 1. Increase in Aggressive bacteria 2. Decrease in Protective bacteria 3. Why does this occur? Infections, antibiotics, food additive?, smoking, NSAIDS

8 IBD Analogy

9 Common IBD Symptoms Symptoms/Signs Crohn s disease Ulcerative colitis Rectal bleeding Abdominal pain Diarrhea Weight loss Growth failure Perianal disease ++ Mouth ulcer ++ + Skin rashes + + Fevers ++ + Low red blood cells Joint pains/swelling + +

10 Matching GI symptoms to anatomy Inflammation in colon: more diarrhea and bloody stools Inflammation in rectum: more stool urgency, mucus, bloody stools Inflammation in small intestine: nausea/vomiting, constipation, weight loss, poor growth, nutrient deficiencies (iron, Vitamin B12, folate, Vitamin D)

11 Goals of Therapy Induce remission Maintain remission Improve quality of life (go to school, work, practice, activities with friends) Minimize side effects of medications Flare #2 Flare #1 Induction of Remission Remission

12 Treatment options Diet* Medications Oral Topical (rectal foam, enema, suppository) IV (infusions) IM (injections) Surgery Complementary (acupuncture, diet) Probiotics

13 Selection of Medications Severity is dependent on: 1. Endoscopy findings (large ulcers) 2. Extent of disease (how much of intestines) 3. Presence of complications Poor growth (short for expected age) Infection (C. diff, abscess) Fistula (false opening in intestine/rectal area) Stricture (intestine narrowing) Severe: Infusions, injections, surgery Moderate- oral, topical, infusions, injections Mild- oral and topical

14 Types of Medications & Delivery Biologics: Remicade, Inflectra: infusion at hospital or home (4-8 weeks) Humira: at home injection (1-2 weeks) Cimzia: at home injection (monthly) Simponi: at home injection (monthly) Entyvio: infusion at hospital (4-8 weeks) Stelara: 1 st infusion, then at home injections (4-8 weeks) Steroids Oral: prednisone, budesonide (Entocort, Uceris), prednisolone Per rectum: Foam: proctofoam, Uceris foam Suppository: hydrocortisone Immunemodulators: Methotrexate: injection or oral 6-MP, Imuran (azathioprine): oral (daily) 5-ASA Oral: Pentasa, Lialda, Asacol, Colazal, Apriso, sulfasalazine Per rectum: Suppository: Canasa Enema: Rowasa

15 Other Common IBD Treatments Supplements Vitamin B12 Vitamin D Folate Iron, zinc Multivitamins Nutritional Supplements Boost, Pediasure, Ensure Probiotics Re-populate with healthy bacteria, yeast Colitis, pouchitis-vsl#3, Align Recurrent C.diff- Florastor saccharomyces Bifidobacterium Lactobacillus, Bifidobacterium, Streptococcus

16 A little more on Enteral Therapy Liquid formula (shakes) to treat Crohn s disease ~75-80% effective in children/adults Exclusive enteral nutrition (EEN) Similar remission rates as steroids Intestinal healing Induction 4-12 weeks to induce remission Maintenance Sole source of all nutrition (100% vs. 80%) Repeat 4 week cycle every 3-4 months Addition of Crohn s medication (5-ASA, 6MP, Methotrexate)

17 Is EEN (aka shake diet ) for me? Predictors of poor response to diet therapy Severe growth failure (malnourished) Inflammation along colon only Foodies Intolerance to volume of formula (may need NG placement) Fistula (opening to skin surface or other organ) Strictures (narrowing of the intestine) Complement other therapies

18 Indications for Surgery Failure of medical therapy Obstruction (vomiting, belly distended, fevers) Intestinal perforation Fistula or abscess (infection) Bleeding requiring blood transfusions

19 Lifetime Risk of Surgery Crohn s disease Ulcerative colitis 10-15% lifetime risk

20 Types of Surgery Crohn s disease Limited intestinal removal (no ostomy bag) Ileostomy or colostomy Strictureplasty Ulcerative colitis Remove colon Ileostomy (temp. ostomy bag) Pouch

21 Living with IBD

22 School & IBD 504 Plan Rehabilitation Act of 1973 that prohibits discrimination based upon disability Strongly recommend ALL patients have a 504 plan Talk to admissions counselors (college-age) Meal plan Dorm options (single room, close to bathroom) Scholarships

23 504 Plan Highlights Go to the bathroom when you need to Private bathroom, i.e. nurse s office. College dorm (single room, close to restroom) A place to keep your emergency supplies Permission to take regularly scheduled and emergency medication at the nurse s office Permission to eat snacks and drink liquids throughout the day Get help with classwork that you missed and have quizzes, tests, and projects rescheduled Stop the clock during tests so you can use the bathroom and not lose any test-taking time Excused absences due to illness, medical appointments, and treatments Even if you are doing well and do not feel like you need a 504 Plan, it is always good to have it in place just in case

24 Websites for Teens and College Students

25 Vaccines Live vaccines (avoid when on 6MP, azathioprine, methotrexate, Remicade, Humira, Cimzia, Entyvio, Stelara or high doses of prednisone) Intra-nasal influenza MMR, live varicella (chicken pox), oral polio Safe vaccines in IBD Influenza shot Pneumococcal Hepatitis B Meningococcal HPV (men & women)

26 Travel with IBD Carry emergency kit Know where you can find clean bathrooms (Starbucks, Jimmy Johns) Tell your doctor if traveling outside of US When to call, see local physician Antibiotics Flying with medications

27 Quality of Life in IBD 25-30% of children with IBD have symptoms of depression and/or anxiety 10-30% meet criteria for clinical depression or an anxiety disorder Stressful life events (school, competitions, friends) Family dysfunction (doctors appointments, hospitalized, surgery, infusions) Steroid treatments (mood changes) These rates are similar to children with other chronic illnesses Mackner, et al. Inflamm Bowel Dis 2006

28 Is there a risk of cancer with IBD? Risk of lymphoma: 2/10,000 general population 4-6/10,000 with certain IBD medications No increased risk with Remicade, Humira Colon cancer Screening colonoscopy 8 yrs. after diagnosis 1-2 years if have a history of liver disease (PSC) Continue colonoscopy every 1-2 years

29 Diet Tips- during flares Eat smaller meals more often Reduce the amount of greasy or fried foods you eat Avoid trigger foods, especially during flares Limit certain high-fiber foods such as seeds, nuts, popcorn, beans, green leafy vegetables, wheat bran, and raw fruits and vegetables Limit drinking milk or milk products if you are lactose intolerant When having diarrhea (flare) Avoid caffeine in coffee, tea, soda Avoid dehydration by drinking extra fluids

30 Active Engagement Research Observational studies Stool, blood, tissue from biopsies Quality of life assessment Adherence Clinical Trials COMBINE Anti-TNF alone vs. Anti-TNF with methotrexate (currently enrolling) Prebiotic study (will be enrolling soon) Social Activism Facebook, Parent advisory, PAC (adolescents, young adults with IBD) Crohn s & Colitis Foundation Kick for Crohn s, Walk, Run, Cycle events Local fundraising for CCHMC FDA

31 Optimizing Treatments Monitoring drug levels for: Infliximab (Remicade, Inflectra) Adalimumab (Humira) Vedolizumab (Entyvio) Ustekinumab (Stelara) Azathioprine (Imuran) or 6-mercaptopurine

32 Medication level in body How the body processes medications Next dose Peak Treatment Goal Time (days) Zero trough

33 Infliximab (Remicade) Gut Healed! 5-10 mcg/ml 1. Increase the dose 2. More frequent infusions (every 4 or 6 weeks) Ulcers Ungar et al. Clin Gastro Hepatol 2016

34 Adalimumab (Humira) Standard dosing: 1 injection every 2 weeks #1 #2 #3 Induction Ask about Maintenance Citrate-Free! 5-12 mcg/ml 1. More frequent injections every 10 days or weekly 2. Increase the dose to 2 pens every week Ungar et al. Clin Gastro Hepatol 2016

35 Entyvio level Vedolizumab (Entyvio) >25-30 mcg/ml 10 mcg/ml 0 4 weeks 8 weeks Time (weeks)

36 New Research Study

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38 Questions? Reminders: Annual IBD Education Day (Feb-March each year) Camp Oasis each summer (Fenton, MI) Take Steps Cincinnati (June 2019) Theodore M. Berry International Friendship Park