Gastroenterologist & Hepatologist Auckland City Hospital Auckland

Transcription

1 Dr David Rowbotham Gastroenterologist & Hepatologist Auckland City Hospital Auckland 14:00-14:55 WS #138: IBD in Primary Care - Practical Management Tips 15:05-16:00 WS #150: IBD in Primary Care - Practical Management Tips (Repeated)

2 IBD in Primary Care Practical Management Tips Dr David Rowbotham Consultant Gastroenterologist Dept of Gastroenterology & Hepatology Auckland City Hospital

3 Disclaimer This workshop presentation is supported by Emerge Health. The views and opinions expressed in the following presentation are those of the presenter and do not necessarily reflect those of Emerge Health Ltd. Emerge Health Ltd does not endorse the use of unregistered products or products outside of their registered indications. Please refer to the Product Information or Data Sheet for licensed instructions.

4 Disclosures Advisory Board Abbvie; Janssen; Baxter; Pharmaco; Hospira Speaker fees Abbvie; Janssen; Baxter; Pharmaco; biocsl; Given imaging; Emerge Health

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6 Outline Aetiology Calprotectin Novel Rx s Stopping treatment Clinical trials (at ADHB) Management tips Clinical MCQs

7 Inflammatory Bowel Disease Diagnosed What s out there

8 Specialist GP

9 GP

10 Understanding IBD behaviours Specialist

11 Crohn s disease behaviour Cosnes, Inflammatory Bowel Diseases 8:

12 Crohn s disease digestive damage Lémann score Pariente Inflammatory Bowel Diseases 17: ,

13 Clinical course of UC Population-based study (the IBSEN study). 454 pts with UC followed over 5 yrs 2006 Inflammatory Bowel Diseases;12:

14 Cumulative colectomy rate in UC Biologic era Population-based study (the IBSEN study)

15 Aetiology? Genetic polymorphisms (susceptibility) Specific environmental factors M. paratuberculosis Oratane (Isotretinoin) Generic immunogenic factor(s) in genetically susceptible individuals

16 Faecal Calprotectin

17 Faecal Calprotectin Auckland labs normal range : 0 50 mcg/g >200 mcg/g sensitivity 70%, specificity 92% PPV 94% NPV 61% in predicting intestinal inflammation

18 Novel therapies? Crohn s Trichuris suis (pig whipworm) Low dose naltrexone (4.5 mg / day) IBD (colitis) FMT (faecal biotherapy / poo transplant) UC (proctitis / distal colitis) Appendicectomy

19 Stopping treatment? 5-ASA Why? Very well tolerated No cumulative side effects (dose or time)

20 Stopping treatment? Immunomodulators

21 Azathioprine withdrawal? Azathioprine (n=40) Placebo (n=43) 0.2 p = Treton X et al. Clin Gastroenterol Hepatol 2009;7:80 85 Time (years)

22 Remission and <10 mg prednisone (%) Azathioprine retreatment? Re-treatment with Azathioprine associated with good response Patients at risk Patients (2 nd course) Controls (1 st course) p = Months Nachury M, et al. Gastroenterol 2003;124(Suppl 1): A-522 (abstr T1381)

23 Stopping treatment? Immunomodulators Why? Significant side effects tend to be immediate If well tolerated, usually doesn t change Skin (BCC / SCC) forever Lymphoma reduction back to baseline

24 Clinical Trials (current/imminent) Selection / Diversity (Filgotinib) Gilead JAK13 kinase inhibitor Moderate - severe Crohn s (phase 3) or UC (phase 2/3) Oral bd Galaxi (Goselkumab) Janssen IL-23 mab Moderate - severe Crohn s IV then SC 8 or 12 weekly

25 Specialists view of colonoscopy

26 Patients view of colonoscopy

27 Tips for GPs Management of IBD flares in the community

28 Tips First presentation or flare Exclude infection Pathogens Parasites CMV Clostridium difficile

29 Tips First treatment 5-ASA (mesalazine) Asacol 400 / 800 mg tabs; 500 mg supp Pentasa 500 mg tab, 1 g sachet, 1 g supp, 1 g enema Asamax 500 mg tab

30 Tips First treatment 5-ASA 5-ASA oral treatment dosage Asacol 4.8 g daily Pentasa 4 g daily Oral and/or topical Doesn t have to be same brand No dose-dependent side effects

31 Tips Escalation 5-ASA 5-ASA dose at least 4 g daily for flares I regularly use >8 g daily 5-ASA route(s) oral and/or topical (can mix brands) No dose dependent side effects

32 Tips De-escalation 5-ASA When do I reduce 5-ASA dose? Do you need to? Clinical remission No dose-dependent side effects 5-ASA oral maintenance dosage Asacol 2.4 g daily Pentasa 2 g daily Oral and/or topical

33 Tips Once diagnosis established Probiotics acidophilus lactobacillus bifidobacteria Diet & Lifestyle triggers? irritants?

34 Tips Natural remedies Probiotics Supplements Aloe vera juice Spirulina Evening primrose oil Beware Womens Magazines!

35 Should I follow a specific diet? Low residue Wheat / gluten-free Lactose-free Anything IBD / IBS

36 Should I follow a specific diet? SCS (Specific Carbohydrate Diet): limits complex carbohydrates, eliminates refined sugar & lactose GAPS (Gut And Psychology Syndrome diet) IBD-AID (IBD Anti-Inflammatory Diet) Paleo diet All similar, exclude most grains (Paleo excludes dairy too) GAPS & IBD-AID small study success; nothing for Paleo Paleo + probiotics (H 2 S vs. butyrate)

37 Tips Corticosteroids?topical in conjunction with 5-ASA Oral steroids dose duration

38 Tips Moderate to severe colitis Prednisone 40 mg/day; reduce 5 mg weekly <15 mg/day ineffective Mild ileo-caecal Crohn s Budesonide 9 mg/day Duration Moderate ileo-caecal Crohn s Budesonide 9 mg/day or Prednisone 40 mg/day EEN no benefit

39 Tips Treatment escalation Disease modifying drugs -?dose Azathioprine mg/kg/day 6-MP 50 mg/day MTX 10 mg bd once weekly

40 Take home messages Exclude infection Suppositories Rx the rectum Enemas Rx the left colon Topical 5-ASAs more effective than topical steroids Think 5-ASA first and last Steroids (last) resort (dose/duration) If worried... call (me)!

41 Do I get bonus points if I act like I care?

42 So how do you become a good doctor? Sir William Osler ( )

43 So how do you become a good doctor? One finger in the throat and one in the rectum makes a good diagnostician Sir William Osler ( )

44 A successful doctor needs three things Samuel Johnson ( )

45 A successful doctor needs three things A top hat to give him authority, Samuel Johnson ( )

46 A successful doctor needs three things A top hat to give him authority, a paunch to give him dignity, Samuel Johnson ( )

47 A successful doctor needs three things A top hat to give him authority, a paunch to give him dignity, and piles to give him an anxious expression. Samuel Johnson ( )

48 Case 1 18 year old female presents with rectal bleeding and mucus, with feelings of incomplete evacuation. Rigid sigmoidoscopy reveals active proctitis with normal mucosa above the rectum. The best initial management is... A. Oral steroids B. Azathioprine C. 5-ASA enema D. 5-ASA suppository E. Rectal swab

49 Case 2 18 year old male presents with rectal bleeding and mucus, with feelings of incomplete evacuation. Rigid sigmoidoscopy reveals active proctitis with normal mucosa above the rectum. The best initial management is... A. Oral steroids B. Azathioprine C. 5-ASA enema D. 5-ASA suppository E. Rectal swab

50 Case 3 65 year old man with Crohn s pancolitis. Stable for years on Pentasa 500mg bd, but now presents to your surgery with gradual deterioration in symptoms with diarrhoea, blood and mucus. Do you... A. Add in regular 5-ASA enemas B. Increase dose of oral 5-ASA C. Add in Azathioprine D. Commence course of oral steroids E. Give course of antibiotics

51 Case 4 30 year old woman with UC (left sided). Diagnosed 2 years ago. Difficult to settle colitis initially, but now stable on 5-ASA and Azathioprine. She arrives at your surgery and reveals she is 7 weeks pregnant. Do you... A. Stop the 5-ASA B. Stop the Azathioprine C. Stop both D. Recommend termination E. Commence folic acid / iodine

52 Case 5 Regular intake of probiotics have been shown to... A. Reduce the number of flare-ups of IBD B. Reduce IBS symptoms (eg: bloating) C. Reduce risk of Clostridium difficile diarrhoea D. All of the above E. None of the above

53 Case 6 Azathioprine / 6-MP are... A. Safe in pregnancy but not breastfeeding B. Safe in breastfeeding but not pregnancy C. Safe in both D. Unsafe in both E. Known teratogens

54 Case 7 MTX is... A. Safe in pregnancy but not breastfeeding B. Safe in breastfeeding but not pregnancy C. Safe in both D. Unsafe in both E. Known teratogens

55 Case 8 With regard to probiotics, true or false... A. All yoghurts contain them B. Capsules are cheap C. Capsules are better than yoghurts D. VSL #3 is the best probiotic strain E. Find a strain that suits you and stick with it F. None of the above

56 Q & A Your turn!