So, my name is Erica Hagee from the Oregon Clinic in Portland, Oregon, and I'm going to do a whirlwind presentation on IBD management, and it will be a lot of slides that I'll try to get through here. Here's my disclosures. Our objectives, we'll review ulcerative colitis and Crohn's disease just briefly, talk about how you make the diagnosis, review some medical management, and then I'll show you kind of how, when I see an IBD patient in clinic, how I look at an established follow-up patient, new patient, and a flaring patient. So, first, we'll start with a polling question. How many IBD patients do you see in a week? This is helpful for me just to know kind of the audience and what they are seeing each week. So, is it zero to five, five to ten, ten to fifteen, or greater than 20 a week? Okay, so it looks like mainly zero to five a week, which is great. Okay, so overview of ulcerative colitis and Crohn's disease. So, the pathogenesis, we know it's multifactorial. There's a genetic component, there's environmental factors, and there's some sort of microbiome disruption that then kind of has this ongoing overactive immune response, where some people will have complete healing after they've had an insult, but other people who maybe have this genetically susceptible host will continue to have ongoing inflammation. Crohn's disease, the hallmark clinical features, diarrhea, abdominal pain, vomiting, fatigue, and weight loss. It is a transmural disease, affects anywhere from the mouth to the anus. It can cause fistulas, as well as abscesses. In this cartoon here, you see that majority of Crohn's disease is in the right colon, 35% involving the ileum and cecum, but then there's distribution throughout the entire GI tract. Ulcerative colitis hallmark features are more so bloody diarrhea, mucus, urgency, tinnitus, having multiple vomits during the day, can have more predominantly left lower quadrant abdominal pain. It is mucosal involvement, and it's limited to the colon, unlike Crohn's disease. You can have extensive or pan-UC involving the entire colon, distal to proctosymoiditis, and then just proctitis. So how do you come with the diagnosis? It's a clinical presentation with endoscopic evaluation, radiology, histology, and pathology. When you're first seeing a patient with diarrhea, abdominal pain, you're suspicious of inflammatory bowel disease. The initial lab markers should include inflammatory markers, such as CRP, and sometimes a sub rate as well. This is not specific for the GI tract, I will tell you, and fecal calprotectin is more specific for colonic inflammation. 40% of patients do not mount a response to a CRP. So that's something to make note, just because you have a normal CRP doesn't mean that they're not having ongoing inflammation. For anemia with iron studies and ferritin, anemia and platelets are the first labs to change when you have active inflammation. You're assessing for dehydration, the electrolytes, malnutrition, looking at their albumin. Within this patient, you're also doing a CILI-X group panel because they're probably coming to you with the first time for diarrhea, and you want to rule that out, in addition to ruling out any infections such as C. diff and considering SIBO as well. Our IVD management goals are, of course, to make our patient feel better. We want them to get back to their work, get their quality of life back, have it not impacting their social relationships or family, but we must have objective measures of inflammation that also improve. We have good data that shows that patient-reported outcomes do not always match the objective data. So, of course, we want them feeling better. We want them in clinical remission, as we would call it. We want them steroid-free, but we also need to see that there's mucosal healing, some deep remission, avoiding hospitalizations and surgery. Treat-to-target is our paradigm now on how we are treating and monitoring our IVD patients. So, you have active disease with mucosal ulcerations and inflammation. You risk stratify this patient, and we're going to talk about that in a couple slides following. You decide on your treatment. You give them, you know, four, six months, whatever, and then you re-evaluate to see if you have met your target. Are they having no symptoms? Are they having no obvious inflammation on serology, the CRP is normalized, the fecal calprotectin is normalized, does the repeat endoscopy look to be that they're mucosal healing? If yes, excellent. Then you continue to follow them, maybe not every one to two years, but every six months to a year with that therapy. Keep on monitoring, and we'll talk about how monitoring is key. If you have not met that target, and you have not made sure that they are in not only symptomatic remission, but there's objective data to support that, then you optimize the drug, you may be changing your drug, you may be increasing the drug amount or decreasing the interval between the drugs or adding something. And then you re-evaluate again in six months, four to six months. So Crohn's disease management. There are ACG guidelines on the Crohn's disease management. I will not read this word for word, it's very cluttered. Some things that I'll point out, I think one of the most difficult patients to treat is a mild Crohn's disease patient. For chronic Crohn's disease, you can use sulfasalazine. Oromosalamines have been proven to not be effective. That being said, I do still see patients that come to us that are on oromosalamines because I think the provider wants to do something. They want to make themselves feel better, so they put them on this, but it has shown that it is not effective. You can use controlled ileo-released budesonide for symptomatic patient, but that's also not a long-term option because it is truly a steroid, albeit GI-specific, not absorbed, and doesn't have the systemic side effects of prednisone, it's not a long-term solution. Moving on to moderate to severe Crohn's disease, you're entering the realm of starting a biologic, plus-minus an immunomodulator, such as an azathioprine or a methotrexate. And then when you're going on to your severe patient that's flaring in the hospital, they're on IV steroids at this point. You're starting an anti-TNF, such as infliximab, to have a quick response. And then also seeing colorectal surgery, if they have any perianal disease and need drainage or c-tun placement, which would occur before you start your anti-TNF. And of course, before you're starting any kind of biologics, such as an anti-TNF, you're screening for hep B as well as TB. And I could do a whole lecture on just the treatment of IBD, but I don't have time for that. So monitoring for Crohn's disease, there are monitoring tools. Like I said, you need to be monitoring them after you start your treatment. It's not like maybe 30, 40 years ago, we used to start them on medical therapy, maybe it'd be steroids or some sulfazalazine, and send them on their way and tell them to come back to us if they have any symptoms. It doesn't work that way. Just like if someone has diabetes or congestive heart failure, you wouldn't start them on something and then never see them again and not recheck their hemoglobin A1c or recheck their cardiac status. So for disease monitoring, there is the Crohn's disease activity index, which I will tell you, I don't really use this in clinical practice. I think it's more for research and clinical trials. CRP, if they're a maker, is an easy serology. Fecal calprotectin, if they have colonic or inflammatory bowel disease in the colon, not just isolated to the small intestine, is very sensitive. And then of course, endoscopic evaluation and imaging. So risk stratification in Crohn's disease, you need to select your patients that are higher risk for disease progression. These patients need to be singled out, and you need to be aware of them. These features for high risk progression include young age of diagnosis at or less than 30 years old, initial extensive bowel involvement, so the entire colon involved, excuse me, possibly some of the small bowel or upper GI tract, perianal disease, and some of the small bowel disease, initial presentation at hospitalization with penetrating or stenotic disease, and believe it or not, tobacco dependence and smoking. That is an individual risk factor, and the one risk factor that is modifiable. Ulcerative colitis management. So when you talk about ulcerative colitis, as I mentioned in the beginning, it is isolated to the colon. It's a large intestine that's involved. We think about categories of disease extent. Do they have proctitis, which is just kind of the rectum, left-sided colitis extending from the sigmoid to the splenic flexure, or extensive colitis, meaning the entire colon is involved. Disease severity. Of course, the patient reported outcomes do matter in terms of bloody diarrhea, abdominal pain, urgency, and amount of bowel movements, but you need to identify the inflammatory burden. Endoscopic extent. Is it mild, moderate, severe? What are the inflammatory markers? Their CRP, their fecal calprotectin. Knowing their disease course. Have they required hospitalization? Is that when they were first diagnosed? How many times have they received steroids? Have they failed to respond to previous medications? Are they medically refractory? Disease impact. How is this impacting their functional life? How is their quality of life being impacted? Are they not able to work anymore because of their symptoms? Assessing disease activity and ulcerative colitis. ACG does have some guidelines for this. The beginning, you know, the top four here, or excuse me, top three are patient-reported outcomes, and then you have your objective markers leading down. So hemoglobin, inflammatory markers such as sed rate, CRP, and fecal calprotectin, as well as your endoscopy. And looking at these, you can kind of determine if a patient is in remission, mild, moderate, severe, and then severe, severe, or full immune colitis. Ulcerative colitis management. We'll review these ACG guidelines here. When you have mild ulcerative colitis, such as proctitis or left-sided, you see that's very mild. You're thinking more of topical therapies, such as your topical mesalamines, whether that be a suppository form, an enema, or a combination of those two with oral mesalamine. Once again, if you're moving on to moderate to severe, you see, and you've failed maybe the mesalamines, you're moving on to steroids to bridge if you need to. You can use extended release, such as usiris, if necessary, but you're approaching biologics at that point with or without immunomodulators. This will be updated. It's actually a great time to be in inflammatory bowel disease right now. We're having one to two new drugs every year being approved. So this will be changing in respect to new approvals of not only the small molecules, but also more JAK inhibitors coming on board and P1 receptor inhibitors. So looking at, this is just a little diagram to remind you of where the mesalamine is going to be effective. So when you're using a suppository, it's very effective in just the proctitis. If you're going to use an enema, you can reach up to some of the left side, but you may also need some oral mesalamine to get the entire left side. Risk stratification and ulcerative colitis looks somewhat similar to Crohn's disease. You're looking to see, is this patient at increased risk for colectomy? Those patients with extensive colitis, deep ulcerations on endoscopy, age diagnosis less than 40, high CRP, need for steroids, hospitalization, C. diff and CMV colitis, put them at higher risk for colectomy. Those low risk patients have limited anatomic extent, meaning they maybe just have proctitis and it's mild on endoscopic evaluation. Colon cancer surveillance. Our IBD patients with colonic disease are at increased risk for colon cancer. The colon cancer increases with disease duration. Surveillance colonoscopy is recommended for all patients who have chronic disease with a minimum of eight years or who have 30% or more of their colon involved. Screening for colorectal cancer in UC proximal to the rectum also begins, like I said, eight years after initial diagnosis. Patients with UC or Crohn's disease, but UC Crohn's disease with PSC, primary sclerosine cholangitis are at much higher risk for colon cancer. So if the patient has IBD plus PSC, they start yearly colonoscopies at the time of diagnosis. Surveillance colonoscopies for our IBD patients with chronic disease at increased risk for dysplasia occurs every one to three years. One to three years generally depends on what their previous endoscopies have looked like. And then dysplasia in UC that's not able to be respected or multifocal is referred to colorectal surgery to consider proctocolectomy. And we don't really have any recommendations for surveillance in small bowel Crohn's disease. I will tell you it's mainly clinician dependent on if they decide how often they want to MRE or CTE depending on the patient's history. The therapeutic drug monitoring could also have a top of a dome. I'm just going to have one slide on this just to explain the therapeutic drug monitoring. Reactive TDM is used when symptoms occur. So patients doing really well on their biologic and then all of a sudden they start having a lot of flaring, breakthrough symptoms. You want to then consider doing drug monitoring to see are the levels all of a sudden too low? Have they developed antibodies to this? Do you need to make a change or adjustment in your medication? They help with guide decision making and more cost effective than just empiric dose escalation when you don't know what the drug level is. When you have proactive TDM, that means you're using it proactively. So the patient's not necessarily flaring, you're using it on a proactive basis. We use this generally when we're inducing a drug at week 14 or week 12 depending on the drug that you have to make sure that the patient does have therapeutic dosing and hasn't developed antibodies. We also use this when we're stopping an immune modulator. So we know that our anti-TNFs, the level may drop a little bit when we take away the immune modulator. So we want to make sure they have good levels before we do that. It decreases the need for rescue therapy and you can optimize your biologic if you're using monotherapy. And then there was a study that showed some TDM results in possibly fewer treatment failures, fewer surgeries, hospitalizations, and fewer chances of development of anti-drug antibodies because you're keeping them therapeutic. So in office management of IBD patients, we're going to look just briefly at a new IBD patient, routine, follow-up, and a flaring patient. So when I see a new IBD patient in our care, we have an IBD clinic and when they're coming in, transitioning to care, we definitely review the records at length. If possible, before the office visit, what disease do they have? Review the endoscopies pathologies. What extent of disease do they have? What's the phenotype of their Crohn's? Is it penetrating, stenotic, inflammatory? What medications have they tried and why were they stopped? Did they lose response? Did they develop antibodies? Did they have an adverse reaction? Having all of that documented is very helpful to follow the patient along. So if they need a change or a pivot in their treatment course, you know what's been used in the past and why it was discontinued. What surgeries have they had? Do they have extra intestinal manifestations? Are you trying to look for drugs that could cross cover? When was the last disease assessment, of course? When were they last scoped? You know, the last thing a patient wants to do is transfer care right away. The first thing you say is, we're going to do a colonoscopy. You need to get the records, evaluate, look at the pathology before you decide to restage them. And then after you get to know them, then you can make more choices or more decisions on possibly changing therapy if necessary. But you don't want to be doing those upfront. You really want to establish that relationship and review those records well. Sometimes you don't have a choice. Established routine IBD follow-up looks different than the new patient. You know, of course, I want to know the patient reported outcomes. How are they doing? What is their number one concern? This is actually, we're part of the Crohn's Colitis Foundation course foundation. It's a quality improvement program. And this is something that has really changed our practice over the past five years. We now really are asking our patient, what's your number one concern? Because it's most of the time, not the clinician's number one concern. As you would imagine, many are concerned about, am I going to lose my insurance? How am I going to afford my drug if that happens? I'm concerned about staying in remission. I'm concerned I want to have a family and I may not be able to get pregnant. You know, you just don't know what the patient is worried about. So this is a really helpful question. We want to make sure that all their labs are up to date. If they're on a biologic, that they're in a biologic lab protocol. As well as immunomodulator protocol following those laboratories. Making sure that they're up to date on their surveillance colonoscopy. Do they have any new extra intestinal manifestations? I always ask my IV patients at every visit. Do you have any eye pain, joint pain, or unusual rashes? To try to catch some of those extra intestinal manifestations. One thing that's been hard with virtual visits, I will tell you, is you don't always get that physical exam. Some of my young patients just don't think that this weird rash that's an open lesion is associated with their IVD. Whereas when I'm in clinic, I'm able to do more of a physical exam. So I have noticed that being a little bit of a barrier with virtual visits. It's also time you go over health maintenance. Majority of our young patients, they refer to us as their primary care provider. Although we encourage them to establish with a PCP. But we're the ones that are taking ownership of a lot of the health maintenance. Of course, their cancer screening, not only in their colon, but also making sure they're seeing dermatology. If they're female, having regular pap smears, making sure all their vaccines are up to date, bone density scan, and then screening for TB, of course, before starting biologics with hep B. Screening for anxiety and depression, as well as making sure that you, like I said, asking that number one complaint, are in tune with the patient's goals and the disease impact that it's had on their lives. Health maintenance. This is just an example of health maintenance and inflammatory bowel disease and what you should be following in terms of vaccines, cancer screening, and other protection. This is on the Crohn's Colitis Foundation website. So here's some IBD templates and some key points that you want to make sure you're hitting when you are seeing your IBD patients. So you want to make sure the disease type, complications, and extra intestinal manifestations are documented. This is an example of our IBD flow sheet. We fill this out and then it carries to each visit thereafter and we modify as medications change or as we add scopes, et cetera. And in a few slides, you'll see what it looks like on an actual note. So Crohn's disease, you want to make sure you're identifying the phenotype. Is it inflammatory? Is it stricturing? Is it penetrating? This is very helpful when a patient calls and the on-call doc that doesn't know this patient says, oh, they're calling with abdominal pain, nausea, vomiting, and you know that you can tell from here, oh, they have penetrating disease. Maybe they have a new stricture or I'm worried about obstruction. And then knowing that up to a third of patients will develop urinal involvement. This is what our template looks like when we're documenting our endoscopic evaluation, imaging, surgeries, hospitalizations, and pertinent medical history. Unfortunately, we still have to free text into this. We haven't been able to pull in from our EMR. So it's brief in respects to these evaluations, but it is very helpful. Here we can document our labs and this does get pulled in from our EMR. Our prebiologic labs that we order, of course, making sure that their TB is done before biologics, hepatitis B, and then all the other labs that we generally do on a regular basis when they're on biologics and immunomodulators such as CBC, CMP, vitamin D, iron, ferritin. And then if they have Crohn's disease or have had previous restrictions, making sure you're checking vitamin B12, folate, et cetera. Here in Oregon, we have a lot of vitamin D deficiency and our IBD patients are at increased risk anyway. So here is an IBD template of medications. So this is very helpful for our patients that are very complex and have had multiple medications as a dropdown. So we can put in the dose and it's dropped down, like for example, in Fliximab, I'll say five mgs per kid or 10 mgs per kid, or if they're on something unusual, like 7.5, you can pretext that in. This is just helpful because once again, it carries over for every patient visit. So we can look quickly as a reminder of what they're currently on and what they were on previously and why it was stopped. Health maintenance, here we can update all of their vaccines that have been completed as well as skin cancer screening and Dexem. And here's what it looks like when it's all written out. This is what's carrying over from patient to patient. You have what they have in this situation, it's endodermal myocarditis, but it could be user crones, their endoscopic evaluation, most recent imaging studies, pertinent medical history, labs and medications, current, and then if that patient has been on other ones, it'll say past. And then it'll also say in there why it was stopped as well as their health maintenance. This is helpful when the patient's coming in, we pre-chart on our patients, but you can just be reminded of, oh, they're due for their colonoscopy. I see that when the last one was done, they're due for their flu shot this year, et cetera. Here's another example of what it would look like for a little bit more of a complex patient who's had more of an endoscopic evaluation here with Crohn's ileitis. And I just wanted to show on the HPI, making sure that all of the pertinent or as much of the pertinent information is up front when you're documenting on your IBD patients. So 44-year-old female, followed by Dr. Whoever or myself with a history of stricturing Crohn's ileocolitis on metalizumab, last seen. So it's been two years, maybe they were lost to follow-up, they're being seen virtually. She had previously been on Humir and Remicade, but developed severe reaction after treatment for many years, then was started on Antibio, which is metalizumab in 2019. So she's been on it for some time. She's had a previous hospitalization with a small bowel obstruction in 2019 and responded to compromptive therapy. Letting them know down here, the most recent colonoscopy was in 2019, where she had a stricture, et cetera, superficial ulcerations. That's just an idea of how to kind of make a concise, beginning first couple sentences when you're seeing an IBD patient in clinic. What happens when you flare? So when an IBD patient calls with a flare, there is some triage that goes into this. And we are lucky, we have a triage room where our nurses answer those phones. And we do have a template that they follow, which I'll show you on the next slide. But you wanna know what medications are they on? When I first started practicing as a nurse practitioner, I thought that, of course, you give a prescription to someone, they start those medicines that day, they never miss a dose, compliance was never a question. Well, I'm now well aware that the data shows that up to 50% of patients will not take your medications as directed, including my IBD patients. And it can be up to a two week delay before a patient actually goes to the pharmacy to get that prescription filled. So one of the first things you ask is, what medications are you taking? Because it can be that, well, I was on a family reunion, I haven't taken my mesalamine for a month. And then it might be an easier fix of, well, let's restart the mesalamine and then get back to us. Or I was on Humira, I lost my insurance, I've been off drug for six months. All things very helpful to know upfront. When was their last biologic? So are they flaring? Is this maybe a situation where you wanna do some drug levels? Always ruling out C. diff infection, there's higher risk with inflammatory bowel disease patients. Making sure that you have objective data to show that this truly is an inflammatory flare, such as elevated fecal coprotectin or CRP. And then if you need to, going on to a flexible pulmonoscopy or CTE. Are they hemodynamically stable? How severe is this flare? Are they starting to get a little bit unstable? Do they need to be hospitalized? We talked about doing TDM if necessary. Are steroids necessary? Do they need to be hospitalized, as I said? Or do they need some steroids to help them get through this flare? One thing that has also been helpful from Crohn's Colitis Foundation being part of this chorus platform is that we now have urgent working slots for our IBD patients. So I have one slot a day before my lunch that I work in an urgent IBD patient. We have a large panel, so it always usually gets filled. And if it's not filled within that day, then they can work anyone in. But this has been helpful at decreasing our hospitalizations and ER visits. So here's the example of the triage flare note that our nurses use. This can help them kind of concisely get questions answered by the patient and sent over to us in a timely manner so we can give them some feedback and direction on what to do next. So some practice pearls. The new guidelines help us understand how to predict outcomes. Screening for colorectal cancer in UC and Crohn's disease is proximal from the rectum to begin at eight years after initial diagnosis. And that should be UC and Crohn's. Fecal calprotectin is helpful in monitoring UC and chronic Crohn's disease, just knowing that it's not something you can use for modality for isolated small bowel disease. Due to the disconnect between patients' clinical symptoms and mucosal healing, you must use objective measures to assess inflammation in addition to monitoring. And we have that benchmark of that serology or fecal calprotectin you want to use to monitor. We use treat to target to try to change the natural history of the disease and prevent complications and surgeries down the road. If a treatment algorithm is not working for that patient, you need to be ready to pivot, make some changes, and then reevaluate. And once again, that goes with disease monitoring is vital for continued long-term remission. So pouring question number two, what are some risk factors for progression of Crohn's disease? Young age of diagnosis, less than 30, initial extensive bowel involvement, perinatal disease, tobacco abuse, or all of the above. Great, awesome. I'm glad that everyone was listening. All right. So it is my pleasure to go ahead and introduce Dr. John Martin, who will be discussing elevation of abnormal LSU.

inflammatory bowel disease

diagnostic process

treat-to-target

management strategies

surveillance colonoscopies

therapeutic drug monitoring