DENVER—With millions of people worldwide living with ulcerative colitis, the disease requires a comprehensive approach that considers the individual needs and circumstances of each patient.
“Our current goals in IBD management are to make the diagnosis quickly and accurately and achieve normal bowel function to improve quality of life,” said Laura E. Raffals, MD, an inflammatory bowel disease expert and professor of medicine at Mayo Clinic in Rochester, Minn. “We’d also like to modify long-term outcomes of the disease, avoiding hospitalization and surgery, eliminating disability, minimizing exposure to steroids, and reducing costs of care.”
But how do you do this? At the 2023 annual Crohn’s & Colitis Congress, Dr. Raffals presented 10 clinical pearls to aid providers in personalizing treatment approaches and optimizing care for patients with UC.
1. Diagnose Early
An early diagnosis is crucial for patients with UC. Unfortunately, Dr. Raffals said, data over the past 25 years have shown that more than one-third of patients still experience symptoms for more than a year before receiving an IBD diagnosis, which can lead to a delay in treatment and increase the risk for complications. “It is important when patients present with red-flag symptoms that suggest something more than just irritable bowel syndrome that we [assess for] a diagnosis of IBD,” Dr. Raffals said.
2. Personalize the Prognosis
Once a diagnosis has been made, it is important to understand the prognosis for that specific patient to ensure proper treatment. Clinicians should consider factors such as age, family history and the extent of the disease to determine whether the patient is at risk for aggressive disease or complications down the road. Dr. Raffals said this helps guide therapeutic options.
3. Avoid Complications
Because long-standing disease can increase the risk for cardiovascular disease in addition to more well-known risks, such as flaring and colorectal cancer, Dr. Raffals said, it is crucial to get the patient’s disease under control to avoid these potential complications.
4. Achieve Mucosal Healing
In the past, the goal for treating UC was simply to get the patient feeling better and off steroids, Dr. Raffals said. However, the field has evolved, and now the goal is to achieve mucosal healing, which is an objective measurement of success. This end point not only ensures that the patient is feeling better but also that the colon has healed and inflammation is under control.
5. Don’t Switch Medications Prematurely
Before making changes to the patient’s therapeutic regimen, it is important to confirm inflammation with objective evidence and rule out other causes of symptoms, she said. Studies have shown that enteric pathogens and fecal calprotectin can be used to determine whether there is still ongoing inflammation and rule out other causes of symptoms. With anti–tumor necrosis factor therapies, in particular, it is important to optimize treatment before selecting a drug with a new mechanism of action. Dose escalation, adding topical therapy and adjusting the dose can be effective ways to optimize treatment before switching therapy.
6. Do Not Mistake Symptoms for Inflammation
Many symptoms of UC, such as abdominal pain and diarrhea, can also be caused by other conditions. “Many patients may continue to have symptoms despite treatment, but it does not necessarily mean there is ongoing inflammation,” Dr. Raffals said. “Therefore, it is important to use objective measurements such as endoscopic imaging and laboratory tests to confirm inflammation before making treatment decisions.”
7. Avoid Opioids
Between 5% and 13% of IBD patients are on long-term narcotics in the outpatient setting, and up to 70% of hospitalized UC patients receive narcotics (Clin Gastroenterol Hepatol 2012;10[12]:1315-1325). Narcotics may precipitate megacolon and are independently associated with increased infectious risks and mortality in IBD patients (Inflamm Bowel Dis 2012;18[5]:869-876) and thus “are not appropriate for pain management,” she said. “The primary method of control for pain should be disease management, and providers should consider alternative methods such as acetaminophen, antidepressants and psychological support.”
8. Remember DVT Prophylaxis in Hospitalized Patients
IBD patients have an increased risk for deep vein thrombosis (DVT) or pulmonary embolism, and prophylactic anticoagulation should be given even in patients with bloody diarrhea (Ann Gastroenterol 2019;32[6]:578-583). Providers should be very proactive about DVT prophylaxis, Dr. Raffals said.
9. Take Ownership
IBD patients have significant preventive care needs. Many prescribed therapies have safety considerations, including cytopenias, heart failure, hepatotoxicity, osteoporosis, infection, malignancy and immunogenicity (Am J Gastroenterol 2018;113[4]:481-517). However, studies have shown that IBD patients do not receive preventive services at the same rate as general medical patients (World J Gastroenterol 2016;22[34]:7625-7644). It is important for providers to take ownership of ensuring that patients are being screened appropriately, Dr. Raffals said.
10. View IBD Care as a Team Sport
A multidisciplinary approach is essential to providing the best care for patients with IBD. This approach not only benefits patients but healthcare providers as well by allowing them to learn from their colleagues and make them better IBD physicians.
The moderator of the session, Florian Rieder, MD, an IBD expert in the Department of Gastroenterology, Hepatology and Nutrition at Cleveland Clinic, in Cleveland, underscored the importance of consulting with a surgeon early in the treatment process.
“Get the surgeons involved early,” Dr. Rieder said, “so they can have a good conversation, set the tone for the future for the patient and give [the patient] the information that they need to make their own decisions.”
A theme runs through the 10 points: The best care a patient with UC can receive consists of time and attention from a team of providers who understand the nuances of care, which can extend outside of the intestinal tract.
Bharati Kochar, MD, MS, a gastroenterologist and IBD specialist at Massachusetts General Hospital, in Boston, emphasized the need for early and personalized patient care. “Respond to your patients and recognize that not every symptom is IBD,” Dr. Kochar said. But, “IBD is something that must responded to in a timely manner—not your ‘next available’ [time slot], which is often six months later.”
—Chase Doyle
Dr. Raffals reported that she serves on the advisory boards of Fresenius Kabi and Janssen.
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