Diagnostic Challenges and Treatment Considerations for IBD

Las Vegas—Irritable bowel disease (IBD) is a chronic intestinal inflammation, typically labeled under 2 umbrella terms: Crohn’s disease and ulcerative colitis (UC); however, other overlapping conditions are also included.

During a session at the NAMCP forum, Joel R. Rosh, MD, director, pediatric gastroenterology, Goryeb Children’s Hospital/Atlantic Health, professor of pediatrics, Icahn School of Medicine at Mount Sinai, discussed diagnostic and treatment challenges associated with IBD.

Dr. Rosh identified 5 gastrointestinal symptoms associated with IBD: (1) abdominal pain; (2) nausea; (3) vomiting; (4) diarrhea; and (5) constipation. IBD is caused by genetics, immune response, environmental triggers, and luminal microbial antigens and adjuvants. Early-onset IBD is typically linked with genetics, while late-onset IBD is likely due to environmental factors and gut microbiota.

Patients with IBD may have unique signatures that predict complicated or treatment refractory disease, said Dr. Rosh. Genetic susceptibility includes family history, host genetics, and gene expression. Immune response includes innate, adaptive, and serological responses. Environmental factors include microbiome, smoking, stress, nonsteroidal anti-inflammatory drug use, and diet. Treatments include biologics, surgery, pharmacogenomics, monitoring, and adherence.

Accurate diagnosis and staging of IBD requires clinical suspicion and appropriate confirmatory testing. Dr. Rosh presented management goals for IBD in terms of establishing a diagnosis:

    • Relieve symptoms
    • Treat inflammation    
    • Treat complications
    • Minimize treatment toxicity
    • Address psychosocial issues
    • Identify dysplasia and detect cancer
    • Improve daily functioning
    • Replenish nutritional deficits
    • Maintain remission

For UC, treatment options often include aminosalicylate for mild conditions; corticosteroids, aminosalicylate, or thiopurine for moderate conditions; anti-tumor necrosis factor (TNF), cyclosporine, or thiopurine for more severe conditions; and colectomy for the most severely affected patients.

For Crohn’s disease, treatment options often include aminosalicylate, budesonide, or budesonide/thiopurine for mild conditions; corticosteroids or thiopurine/methotrexate for moderate conditions; anti-TNF, or thiopurine/methotrexate for more severe conditions; and natalizumab for the most severely affected patients.

For both, therapy is stepped up according to disease severity at presentation or failure at prior step. “‘Step in’ [therapy] is better than ‘step up’ [therapy],” said Dr. Rosh.

He then discussed predictors of poor treatment response or colectomy:

    • Serum albumin
    • Erythrocyte sedimentation rate >30 mm per hour
    • Bandemia
    • Prolonged flair
    • Active infection
    • Hospitalization setting
    • Severe endoscopic lesions
    • Disease duration
    • Stool frequency
    • Percentage of blood stools
    • Body temperature >37.5° Celsius
    • Heart rate >90 beats per minute
    • Increased C-reactive proteins
    • Toxic megacolon
    • Low hemoglobin <10.5 g/dL

Dr. Rosh noted that the evolving goals of therapy for IBD include sustained deep remission. In terms of treatment goals, the process is response, remission, and deep remission. In terms of clinical parameters, the process is improved symptoms, no symptoms, and normal endoscopy. In terms of outcomes, the process is improved quality of life, decreased hospitalization, and avoidance of surgery.

A personalized approach to treating IBD, including risk stratification, should be adopted, according to Dr. Rosh. Treat to target goals should be implemented for IBD management, which includes regular assessment of disease activity using objective clinical and biologic outcome measures, adjustment of treatment if goal is not being met, and enabling better outcomes in rheumatoid arthritis, hypertension, diabetes, and hypercholesterolemia.—Kerri Fitzgerald