Complicated Case Scenarios in IBD:What we know and what can we do?

Moderators: Miguel D. Regueiro, MD, FACGCorey A. Siegel, MD, MS

Cases (30 minutes each)

1. Managing IBD in the Setting of Infection - Panelists: Jessica Allegretti, MD, MPH; Marla Dubinsky, MD; Edward Loftus, MD; Séverine Vermeire, MD, PhD

2. The Road Ahead for Pediatric IBD, The Adolescent Dilemma: Cases Studies - Panelists: Michael Kappelman, MD, MPH; Alan Moss, MD; Eva Szigethy, MD, PhD; Joel Rosh, MD

3. Inflammatory Pouch Disease: What is it and how do we manage it? - Panelists: Jean Ashburn, MD; Hans Herfarth, MD, PhD; Laura Raffals, MD; Scott Strong, MD

Case Discussion I

Managing IBD in the Setting of Infection and Vice Versa

Panelists: Jessica Allegretti, MD, MPH; Marla Dubinsky, MD; Edward Loftus, MD; Séverine

Vermeire, MD, PhD

Management of an abscess while on combo therapy

§ 20 year old female college student, recent diagnosis of ileal Crohn’s (30cm+), on adalimumab + 6MP x 3 months, admitted to the hospital with fevers and a 2cm abscess within an ileal phlegmon. IR doesn’t think they can drain it. What are our next steps?

Take home points:§ Need to drain abscess when able§ If unable, need to minimize immune suppression and treat with antibiotics and

serial imaging§ Avoid corticosteroids§ Hold doses of biologics and immunomodulators as long as able, but also need to

treat underlying inflammation (which caused the problem in the first place)§ Consider overlapping antibiotics when restarting Crohn’s directed therapy

Managing C. difficile in the setting of a UC flare

§ 53 year old gentleman with UC on infliximab + azathioprine, admitted to the hospital for a “flare,” started on IV steroids, found to be C. diff +. What do we do with his meds?

Take home points:§ There is often a flare + C. diff, need to treat both§ Make sure you are dealing with a “real” C. diff infection§ Need to minimize or eliminate corticosteroids§ Need to maximize appropriate C. diff treatment§ Anti-TNF can be used as needed, ? some concern about vedolizumab

EBV while on combo therapy

§ 26 year old male graduate student with ileocolonic Crohn’s disease in remission for 3 years on adalimumab + AZA. Presents with fatigue, headaches, low-grade fevers, lymphadenopathy in neck, and EBV+. How do you handle Crohn’s meds now and in the future?

Take home points:§ Consider checking EBV status before initiating thiopurines (? Mtx)§ Hold immune suppression while recovering from EBV§ Follow clinical status to guide restarting of immune suppression§ Immunomodulators (thiopurines +/- methotrexate) likely the concerning

medication, biologics less so. § Restart biologics as soon as able, then discussion over benefits:risks of continued

immunomodulators

Case Discussion II

The Road Ahead for Pediatric IBD and Transition to Adult GI: Cases

Panelists: Michael Kappelman, MD,MPH; Alan Moss, MD; Eva Szigethy, MD, PhD; Joel Rosh, MD

Case II Discussion questions

§ 18 year old male relocates with his family to a new city. He was started on Infliximab and 6MP six months ago for fistulizing Crohn’s disease, also uses Med Marijuana. Is “doing well”.

§ 14 year old female diagnosed with severe ileal Crohn’s disease at 9 years of age, low on the growth curve. She has failed infliximab and the family is asking about other therapies.

§ 17 year old female with severe ulcerative colitis transitioning to your adult GI practice. She had a reaction to infliximab but is doing well with vedolizumab. She has depression, a lot of stress related to school and her IBD, and doesn’t want to be on meds for her IBD.

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How do you manage a teenage male patient with fistulizing Crohn’s disease?

18 year old male relocates with his family to a new city. He was started on Infliximab and 6MP six mos ago for fistulizing Crohn’s disease. Uses Med Marijuana. Is “doing well,” but IFX level is undetectable (no Anti IFX abs) and 6TG 0. Take home points:

§ Understand that thiopurines carry lymphoma risks, especially in males (young and old). But, absolute risk very low

§ Consider risk/benefit of medications. Factor in non-adherence§ De-escalation off of 6MP with IFX = ensure deep remission, check pre- and post- de-

escalation IFX TDM § Check EBV prior to 6MP? MTX is not without risk§ Medical marijuana no proven IBD efficacy, has risk

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How do you approach young patients with severe IBD?14 year old female diagnosed with severe ileal Crohn’s disease at 9 years of age, low on the growth curve. She has failed infliximab and the family is asking about other therapies. Take home points (very) early onset IBD now coming to adult GI:

§ Discuss nutritional therapies and growth issues in pedi IBD§ Endoscopic testing is a “big deal” in kids. Often an EGD and colonoscopy are performed

simultaneous with MAC. § “Treat to target” for pediatric IBD is more than endoscopic improvement§ Infliximab and Adalimumab are the only biologics approved for pedi CD (IFX for peds UC), how do

you approach “off label” biologics in pediatric patients?§ The role of surgical resection as early therapy in limited CD§ Understand the approach to (very) early onset IBD (< 5 years old) with exome sequencing

(monogenic), also rule out immunodeficiency sydromes

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What do adult GI’s need to know about transitioning IBD care from a pediatric patient?

§ 17 year old female with severe ulcerative colitis transitioning to your adult GI practice. She had a reaction to infliximab but is doing well with vedolizumab. She has depression, a lot of stress related to school and her IBD, and doesn’t want to be on meds for her IBD.

Take home points:§ Checklist of factors for Adult GIs when transitioning care§ Defining Transfer of Care (passive) from Transition of Care (active)§ Understand the psychosocial impact of IBD and how to manage depression§ Adherence requires shared decision making, building trust, and incorporating team-

based care, especially in young IBD

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§ Recognizing and reconciling differences in approaches to care between pediatric and adult providers§ Differences in style§ Differences in management§ Differences in time allotted for office visit§ Differences in procedures and sedation

§ Planning for care at college/time away from home§ Balancing parent and patient interests§ Preparing the complete medical summary letter

Preparing for Transition of Care

Transition ≠ Transfer to Adult Care• Transfer: the move from one provider to another. Single act.• Transition: the purposeful, planned movement of patients toward independence, autonomy

and self-advocacy. Process• Knowledge• Disease Self-management• Emotional readiness• Self-advocacy• Available resources

• Developmental ranges of appropriate milestones• Age 12-14: Type of illness, Rx, Adherence• Age 15-18: Nutrition, self-management, reproductive health, insurance• Age >18: Self-management, New health providers

• Website Resources: • CCF www.justlikemeibd.org/ : • Doc4Me app • NASPGHAN https://www.gikids.org/files/documents/resources/IBD-TransitionTeenIBD.pdf.

Blum RW 1993; Ferris, 2012

Case Discussion 3

Inflammatory Pouch Disease: What is it and how do we manage it?

Panelists: Jean Ashburn, MD; Hans Herfarth, MD, PhD; Laura Raffals, MD; Scott Strong, MD

New onset pouch symptoms (not a trick question)

§ 36 year old woman, IPAA (J-pouch) 3 years ago, with baseline 4-5 BMs daily (0-1 nocturnal) now with 3 weeks of 8-9 BMs daily and 2-3x/night. What are the steps in our evaluation and treatment?

Take home points:§ Evaluate and make the diagnosis (common things commonly)§ Ciprofloxacin and metronidazole and are best studied for pouchitis§ Duration of treatment 2-4 weeks§ Consider roll of probiotics for prophylaxis against future bouts

Antibiotics worked and now they don’t§ Same patient, now 38 years old. She initially responded to ciprofloxacin or

metronidazole over the past 2 years, but she now says these “don’t work anymore” despite continuous antibiotic treatment. Repeat pouchoscopy with diffuse moderate pouch erythema, few small erosions, no ulcers (ileum above pouch normal). What is this and what do we do next?

Take home points:§ Recognize antibiotic-dependent and antibiotic-refractory pouchitis§ Evaluate for secondary causes and consider the differential diagnosis§ Treatment options include the range of IBD treatments (5-ASAs, budesonide,

immunomodulators, biologics, dietary therapy, fecal-microbiota transplant, ? hyperbaric oxygen therapy)

Beyond pouchitis§ 44 year old gentleman with UC, IPAA 6 years ago and had no issues for the first 5 and ½

years (5-6 BM daily, 1-2 BM at night) Over the past 6 months he’s experiencing more frequent BMs, occasional blood, abdominal cramping, and he’s lost 5 pounds. Pouchoscopy with a number of moderately deep ulcers (away from anastomoses) on background of erythematous mucosa, early inflammatory stricture at the pouch inlet, and small ulcers to approximately 20cm above the pouch. No fistula. What could this be and what do we do next?

Take home points:§ Consider the differential diagnosis§ Careful with the term “Crohn’s disease of the pouch” § Treatment options include the range of IBD treatments, but typically require biologics§ More data emerging about biologics§ Consider surgical options