All right, everyone, we have a lot of questions I'm planning on us just going through up until our time for lunch, which will be 1225. Anything we don't address we will write back so if we don't get to it today just while we're chatting. Rest assured, we will get your question answered. I'm going to start us off Jill there's a few series of questions about celiac disease and the testing markers so I was going to start with those. So the first question is, what exactly is a celiac disease test measuring and why are we asking them to add gluten back in. So, celiac disease is an autoimmune disorder and gluten is actually destroying the villus in the, in the small bowel or small intestine. So, the, the tissue trans glutamine marker is actually measuring how much of that destruction of the villa is actually happening. So if you take out gluten from a patient's diet, then you've cured them, or in essence you're helping them become better. So you're taking away the trigger which is causing the destruction. You need to mimic the destruction to get a diagnosis so you need to ask patients to add the gluten back into their diet. Thank you. There is another question about IgA IgG, or I'm sorry IgA levels to kind of in the same vein, how do you explain if the TTG IgA is normal but the IgA is elevated, and then how elevated of an IgA level. Do you see before you start getting concerned. So usually my patients that's the first question though, they'll ask me and their portal message when they see a celiac panel is that their IgA level is elevated and they're concerned about it and I have to reassure them. There's no additional workup for an elevated IgA level. If it's low, then you have to take a look at the patient you know do I need to refer them to an immunologist, because now their IgA level is so low, then they need an evaluation for IgA deficiency, but it's the lower ones that you'd have to be more concerned about than if they're elevated so I provide reassurance to my patient. If it's elevated. Perfect. And then one other question and kind of along the veins for celiac disease. What do you recommend for patients with a positive TTG and a negative endoscopy. So I would follow those patients, follow the patients and find out, bring them back in your office and find out if they stopped gluten between the time of a positive TTG, and the endoscopy, and then look at your endoscopy and see if there was a good sampling for the, for the small bowel, and then continue to, I would continue to monitor the patient. So, you may want to put them on a gluten free diet and see if you can bring that TTG level back down again, so you haven't followed the gold standard. But you, you know that the TTG is elevated so most likely that they do have a diagnosis of celiac disease. Yes, we have, we have a lot of great questions here we're going to try to go back and forth some for Jill and others for Amy. Let's start with another IBD question here. Patient specific. There's a 27 year old man with Crohn's disease of the large intestine who has been doing well on Humira and Misalamine for about one and a half years with histologic and symptomatic remission. Last month developed more frequent stools, elevated fecal calprotectin and Humira level was undetectable with elevated antibodies. So the plan is to change him to Stelara and the question is with regards to is there still a recommendation for this patient to also do methotrexate or other agents to decrease the development of antibodies and resistance. So that's a really good question. Couple of things here. One is that the IL-23s you don't really need to worry about antibodies with, right? So with Stelara, I would not add on methotrexate or azathioprine to reduce risk of antibody formation. If you were switching this patient to another anti-TNF, yes, I would consider adding an immune modulator as well to prevent antibody formation and really early drug level monitoring. So that is someone I'd probably check their drug level early, maybe at week 6 and then again at week 14 to make sure we've got adequate levels to prevent antibody formation. Stelara is certainly a reasonable option. The IL-23s are also reasonable options to do in that patient as well. Excellent. Thank you. What is your go-to biologic agent of choice for patients who have a history of melanoma or other malignancies? It's a hard question. It certainly is patient-specific, but I would say in general, malignancy history, fetalizumab is my go-to. If I had to pick one that was the least likely to cause melanoma or malignancy, it would be fetalizumab. Excellent. I have another question here. I think this is specific to Skyrizzy. After the first three months, how often are you checking lipid panels if there has not been any elevation? And if there has been an elevation in the lipids, do you continue to monitor or do you consider changing to alternate therapy? After the first three months, I don't keep typically checking lipids. They should be getting that annually with their primary care. If there's an elevation of lipids and they're not responding to therapy, then yeah, I likely would pick something else. But if they're responding and doing really well and their lipids can be treated, I would talk to their primary care about considering that. Excellent. Thanks. Maybe we'll do one more IBD and then go back to some for Joe and we can keep going. For a newly diagnosed patient, at what point during or after steroid therapy is it safe and or appropriate to start the therapies beyond misalamine? And is misalamine stopped after induction dosing is completed or prior to that? When do you consider that change? Great question. So when you're starting steroid therapies, you're thinking about how you're getting them off. So you're also starting your advanced therapy as soon as you can get it. A quick note that I would recommend trying to get the quant gold particularly drawn before steroids, because it often can be indeterminate if your patient is on steroids when it is drawn. So try to get that done early. If you're thinking advanced therapy, get a quick quant gold. You don't need for the results to come back to start therapies, but have that drawn first. And then as soon as you can get your advanced therapy, you're starting it. I typically keep them on steroids through at least the first induction dose, depending on how they're doing. Start to taper after that. Misalamines, I usually wait a little bit longer to taper because they're not hurting. They're just not helping. But I don't like to have too many variables during induction. So I definitely wait until after induction, sometimes even through that first or second maintenance dose before stopping the misalamines. Excellent. Great. Thanks. A couple of questions for SIBO. So for SIBO treatment, methane-dominant and for vaxmin is not approved. What do you usually give? It looks like this provider has been giving flagell, but the data is a little bit confusing whether you should do flagell with neomyosin or flagell alone. I would use flagell alone in that scenario. OK, perfect. Thank you. Are there any dietary restrictions prior to SIBO breath testing? There are some specific diet requirements based on the TRIO smart breath test. So I follow the inserts and patients are educated by my staff specifically on the diet requirements. So, yes. And then one other SIBO related question. How would you explain the difference between SIBO and IMO to patients? Well, that's a tough one. So IMO is going to be basically more patients who have constipation. So, I mean, it's actually easier than I think. So patients with SIBO have more diarrhea predominant. And if IMO, they have more constipation predominant. So it's just going to be the gas that's been expressed in their in their gut to form a different gas than the other. I actually have one follow up on that. So if you have a patient with a methane positive SIBO, but has diarrhea and not constipation, how do you proceed? So I proceed based on the guidelines. So I'm going to treat based on the IMO guidelines, what the recommendations for the medications are. We can do a couple more questions. I was going to say a caveat for those types of patients. And always be mindful about bulking up a patient too much if they have diarrhea predominant, because then that's also going to cause bloating too. So it's prudent to all of us to review their diet, even to the point of if they're on a psyllium based fiber supplement, because psyllium is going to cause bloating. I'll bring patients back to use a product like Benafiber, which is guar gum, which is going to cause less bloating in my experience. And then even try them on Heather's tummy fiber, which is an acacia based fiber. So having that conversation and reviewing their diet is going to be more beneficial in the long run than having a positive SIBO test and the patients wanting to chase that value. They really look at those SIBO results. They look at those parts per million, and they want to start getting retested and retreated every six months to try to bring that down again. Thank you. We'll do a couple more IBD questions. So we have a patient with, it sounds like a new diagnosis, chronic diarrhea and abdominal pain as symptoms, but colonoscopy shows ileitis. What initial treatment would you recommend? It's a good question. So first I would look at the rest of the small bowel, right? So we can only get to a little bit of that small bowel on colonoscopy. So either looking with a capsule study, which is more specific for kind of milder, more subtle disease, or something like an MR enterography or CT enterography. So make sure we know what we're working with before starting treatment. That's a little bit tricky one. That is someone that I'd probably try a course of Budesonide and see if they respond. And if they do, that is a patient that I may consider an advanced therapy in. Vitalizumab is not usually my first choice for Crohn's disease, but in this scenario, I would absolutely consider it. There might be some people who consider azathioprine in that case too. If the patient had no symptoms, you could consider watching and waiting with Calprotect in every three to six months, but it kind of depends on all of those factors. Great, thanks. Kind of a little bit of a follow up there. Let's say you do start this patient on steroids and you're trying to use that as bridge therapy. When's the best time to start the next therapy? For instance, if we're starting with ASA. So if we're starting with an ASA, right away, right now, don't delay. Keep it going. As soon as possible, get them on it. Perfect. I have a couple more questions here. So for dysbiosis and IBD, if dysbiosis is implicated in the development of IBD, what are the current recommendations with regards to probiotics? Good question. There is no data that probiotics help long-term in inflammatory bowel disease, nor things like fecal transplant. Do I think that in the next 10 years, our understanding of this is going to shift and recommendations might be different? Yes. Do I use rifaximin in patients who have overlapping SIBO with IBD? Absolutely. Excellent. I have a question actually about inpatient management for a patient with previously untreated ulcerative colitis and is presenting with an exacerbation or presenting with a new diagnosis. And they're not responding to IV steroids after 72 hours. Do you recommend considering emergency infliximab or what are your alternative options? Yes. I would absolutely use infliximab in an acute severe UC patient. This patient is also someone that we are having surgery follow along with us daily. The first time you meet this surgeon, you don't want it to be when you're sprinting down the hallway with a perforation, right? So having surgery on board, knowing that that might be the case. If your patient had previously been on infliximab, that is someone that I or previously didn't respond to infliximab or another TNF. That's someone that I would consider using a jack in inpatient as well. Excellent. Should we show it back to Caitlin? Yeah, we could. I have a couple more for Jill. Both of these questions are talking about fiber, either a fiber trial or a probiotic trial for diarrhea or IBS. What your thoughts on fiber and probiotics are? What's the kind of other acute cause of the mineral though? So I always start with a fiber supplement, but I take it very slowly because that conversation, because some of my patients will say they've already tried it before and it caused much more severe bloating and abdominal pain. So those conversations I gently walk into because I say, if you haven't, tell me about your experience about using a fiber supplement. Because again, psyllium-based fiber supplements can cause bloating. But those are the most common toolkits in our armamentarium to try to step up their fiber. And of course, I talk about foods, eating whole foods, avoid processed foods. And as Amy mentioned, even in IBD, there's not a lot of good data on the use of probiotics. One of the clear studies was that there was probiotics that was beneficial for patients with pouchitis, but the other probiotics are far and few between. And I take the time to go over my patients, the use of probiotics and whether they're on them. And I'll explain to them the data, but also that I want you to have clear, measurable objectives if you do start a probiotic. And the ones that I recommend to try are Align, Culturelle, and Floristore. But I said, let's have mutual agreement on you seeing if there's a benefit. So we want informed, we want formed stool. We want to reduce the number of bowel movements. But I said, let's give it four to six weeks to see if there's a difference because our patients put so much stuff in their mouth that they purchase over the counter. And we don't know what they're taking. And it behooves us to find out what they're taking. You know, I have patients that come in with elevated liver enzymes and they're on Oxbile is the one I'm seeing more recently for chronic diarrhea. I don't know if my colleagues have seen that as well. So Oxbile, we've got turmeric, we've got, you know, other herbal products that are proprietary blend. And I explained to patients proprietary blend means that we have no idea what you're taking. So when I'm working at patients with elevated liver enzymes, I say you stop all non-essential supplements. I'm getting a little excited about this topic because it's something that we talk to our patients about every day. And if we don't ask them about it, we don't know they're taking it because they are. And I explain that this is, you are adding on your additional monthly expenses, 40 to sometimes $60 a month to take this stuff. And I want you to understand whether this is purposeful or not. Did I answer the question? I think you did. You did fiber and probiotics and not turmeric. So I give it a trial, but I explained to them. I don't want you to take something if you're not going to get benefit from it. I wanted to ask this question to Jill or anybody on our panel. Do you have a virtual CBT program that you recommend for institutions that don't have access to a GI psychologist? I don't personally, no. So yes and no. So for CBT specifically, there is a group GI psychology, which is based in Northern Virginia that is all telehealth. They're out of network with insurance. I don't know if they see people in all 50 states or it's my D.C. metro area. There is an app for gut hypnotherapy to work on the brain gut connection called Nerva that you can download. Patients can download for the brain gut connection, but not specifically for CBT. Fabulous. That's why I wanted to ask that. I wanted to see if anybody else had input too. So great. Okay. I think we're hitting up into lunch right now. So we're going to stop this question and answer. If you have any other questions, please feel free to quickly enter them in the chat. We'll have Amy and Jill take a look at them and get them all answered. Sorry if we did not get to them now. We will resume after our lunch break at 1 o'clock.

gastrointestinal disorders

celiac disease

Crohn's disease

SIBO

biologics