Fatigue and IBD With Dr Sara Horst and Dr David Hudesman

In this podcast, Drs Sara Horst and David Hudesman discuss quality of life and effects of fatigue on patients with inflammatory bowel disease.

Sara Horst, MD, is an associate professor of medicine and affiliated with the IBD Clinic at Vanderbilt University in Nashville, Tennessee, and also serves as Section Editor for IBD on the Gastroenterology Learning Network. 

David Hudesman, MD, is codirector of the Inflammatory Bowel Disease Center at NYU Langone Health in New York City, and also serves as Section Editor for IBD on the Gastroenterology Learning Network. 

TRANSCRIPT:

Dr. Sara Horst:  Hi, I'm Sara Horst, a gastroenterologist at Vanderbilt University Medical Center in Nashville, Tennessee. I specialize in the care of patients with inflammatory bowel disease. I'm here talking with one of my colleagues.

Dr. David Hudesman:  Hey, Sara. I'm David Hudesman from NYU. I'm co-director of the Inflammatory Bowel Disease Center here.

Dr. Horst:  I'm excited that we got to come together today to talk about some work we've been doing on a really important topic that is getting more and more play in the literature and in research.

It's important to highlight it today, and that is around what happens in a patient who has inflammatory bowel disease as far as their quality of life, their patient-reported outcomes, things like anxiety, depression, fatigue, overall health.

Also, something that I think we think about, a lot for our patients that may have been a little bit understudied until recently, which is more productivity, which can be affected in IBD.

We wanted to start by talking about a project we've been working on with the Corona Registry. I thought maybe you could give us a little introduction and talk about it a little bit.

Dr. Hudesman:  Sure. To echo what Sara said, these are very important topics. A lot of times, when we're seeing our patients in the office and you're focusing on how often they're going to the bathroom a day and abdominal pain, it could be easy to forget about some of those quality-of-life metrics, which are really important and probably just as important if not more important than some of our goals of treatment.

We're hoping that some of this research that we're doing and we're starting to look at could be impactful for the patient and improve the patient's quality of life.

The original Corona Registry now changed to CorEvitas—I think trying to distance itself from the word corona in general. It's this national registry, and it was started for inflammatory bowel disease around May 2017.

Now there's over 60 sites across the country, both private practices, academic institutions, and collecting data on patient demographics, disease duration, disease phenotype, what meds these patients have been on, and outcomes.

In addition to this, there's a lot of surveys that are collected not only about the disease activity but also about these quality-of-life and work productivity measures that Sara has just been talking about.

Dr. Horst:  It's important for us to then think about the patient-reported outcomes. This was a nice study looking at things like anxiety, depression, fatigue, and with sleep disturbance, which is important in pain, interference, and then also work impairment.

You can look at things. There's lots of different metrics, but there was absenteeism, which is the number of hours missed, presenteeism, how are they impaired when they're there, work productivity, which is overall loss and overall activity impairment.

These are very nice endpoints in a large number of patients throughout the country in a variety of different GI centers, private practice, and academics. We've got a nice view of what's happening.

One of the things first that we learned about in the study was the high level of impairment that happens in patients with IBD. I was very impressed by this. Both in Crohn's and ulcerative colitis, the presence of any disruption in PROs was pretty significant.

Dr. Hudesman:  Definitely, and especially the measures we used, as you said, and the way it was broken down, everything from fatigue, anxiety, depression. When we're talking about work productivity, and especially now, people mostly think about are they making it to work or not.

The fact that even when they're at work, they're not performing to that type of level, and these measurements are important to show that. Again, across the board, anywhere from remission to severe disease, there were high levels of impairment for both the quality-of-life metrics as well as work productivity.

Dr. Horst:  One thing that I saw, too, disease activity did affect it. For sure, patients who had more moderate to severe disease were more likely to have worse PROs and were more likely to have work impairment.

We care about that when patients are flaring, things are going to feel worse for them. They're going to also have a significant impact on their work. I use that and talk to patients and say, "Remember, we really need to try to prevent a flare for you happening again, because look what happens to you in your life and work."

Dr. Hudesman:  Besides that, nice correlation with it, again, the more severe disease, the worse the outcomes, the patients in remission and couple of these numbers. This is why our goals of treatment; we need to be better. We need to do better and maybe our biologics or small molecules or our aminosilanes, whatever we're using, are not enough.

Even our Crohn's patients that were in remission, and remission in this study was defined by Harvey Bradshaw, so some subjective markers, but over a third of them had significant fatigue, under 20% had depression, and over 50% of them had some type of work productivity.

These are patients in remission. We're happy. We're hitting our target. We talk about treat to target all the time. They're feeling good. However, despite this, they're not doing great with these qualities-of-life and work productivity measurements.

Dr. Horst:  That was impressive to me, to see that people that we define as in remission, to see how much this still affects their life not only in the quality-of-life measures, but actual work productivity—they might be at work, but it's affecting their work.

It's something that we as GI docs need to pay attention to. If that's happening to them in remission, imagine what happens to them when they flare again.

We need to work on helping them get some of these quality-of-life measures improved, even if they are "in remission." We also need to help them remember, "We have to help you try to stay as close to remission as possible."

The high numbers of fatigue, I thought that was a very interesting point. Also, fatigue's getting a lot more interest in research. I try to ask about it a lot. It can be frustrating for patients, trying to help them figure out how to manage that. It's a big aspect of the study.

Dr. Hudesman:  You would think, or I would think patients that have had disease for longer, on multiple medications, sure, maybe it's a little more likely they have fatigue. On multivariate analysis accounting for all of these different factors, still, fatigue in remission, accounting for disease duration, accounting for what meds they were on or have been on still came up.

This is a very important study that was submitted for publication because there's been a lot of talk about it recently. This is one of the largest sample sizes we have that detailed, looked at these measures.

The next question, which is it's great that we're bringing this to light, but what do we do about it? How do we approach it?

It's nice to start seeing in some clinical trials now, they are, for secondary endpoints or exploratory endpoints, starting to include some of these measurements. Again, bringing this to light, but the next step is how do we address them?

Dr. Horst:  We're in the infancy of that. We're learning more about it as IBD providers. We're learning to pay more attention to it and to think about it a lot more. I definitely try to make sure I'm asking about this.

I'm paying attention to these health-related quality-of-life factors. I'm trying to ask a lot more about it now. Like you said, treatment is sometimes difficult, but at least talking about it so that patients don't think this is just part of my life, at least we're trying to think about it and address.

The next 5 to 10 years we're probably going to be making some major headway, I hope. As, like you said, clinical trials start paying more attention to it and we don't only think about disease in the gut, we'll start to see major headway in that direction.

Dr. Hudesman:  I agree. The dialogue is important. A lot of times, I think patients just put it in the back of their mind. They don't even think about speaking about it, think it's normal. Getting that going, talking about it will help them to some extent.

Then it's going to be is there a mechanistic reason for some of this, which is, I think, in my mind, part of it, and then also bringing in that multi-disciplinary approach with psychosocial support, nutrition. Again, as you said, addressing these issues with the patient are going to be key.

Dr. Horst:  When you see someone with fatigue, I'm sure you probably have a little algorithm that you go through. Tell me a little bit about what you do.

Dr. Hudesman:  It's a great question, and it's tough. When they say they're fatigued, this is something that is pretty common, and the differential is very broad. Initially, I try to rule out some things I could treat easily. I check their vitamin levels, possibly some thyroid studies. Are they anemic and so forth? Do they need vitamin D or vitamin B12?

I assess if they're actively inflamed, especially in a Crohn's patient, has symptoms that may correlate, whether I check a CRP or fecal calprotectin. I see what medications they're on. Have there been any change in medications? Is it relatively new medication?

A lot of our patients go on these therapies. The major side effects are uncommon, but some people could have some fatigue side effects, whether it's the medications we're giving or another provider.

That's usually my initial evaluation, again, to rule out or treatable causes. If that doesn't pan out, usually I do give questionnaires to my patient, and I use a PHQ-9 screening for anxiety or depression.

As you mentioned, Sara, I also talk to them about work and other social factors to bring that to light. If I rule out those initial causes, then, again, that's where it becomes a little more difficult.

That's when I spend some time seeing what things I think may be driving it and working with them to see whether it's referring to one of my psychologists or nutritionists, whether it's sending them to the Crohn's & Colitis Foundation for support groups, whatever it may be. That's the next step for me.

Dr. Horst:  You hit all the high points. For me, I do sometimes look at medicines. Some of the big ones that we have patients on are azathioprine and methotrexate that I think can contribute. Could we maybe ease those down or work towards trying to get them off? That's something I think about.

I all the time look at depression and anxiety. It's an under-appreciated cause of fatigue, and so definitely dig into that a little bit more to talk to them about that.

We have some supports. In the US, we could be doing better as a society about helping people get to psychological therapies, such as cognitive-behavioral therapy and things like that, which are helpful. I try to start moving the needle towards that if I think that's something they're going to need.

For sure, I spend some time thinking about diet and exercise. Exercise is something we don't talk about enough to our patients. They're like, "I'm so fatigued. How can I even exercise?" but try to move them closer to understanding that that actually could help them in the long run.

Dr. Hudesman:  Especially with this past year with COVID, people are just sitting down. You always ask about weight loss. Most of my patients have gained weight this past year, sedentary lifestyle and so forth.

Dr. Horst:  When you're fatigued, trying to do any movement seems overwhelming. I've tried to start small and try to help them get little manageable goals. It might just be going outside for 5 minutes and walking. Doing something like that might be somewhat helpful.

There's some intriguing new things. There was a small study looking at something like high-dose thiamine replacement for 4 weeks for patients who had fatigue. We're learning. People are paying attention to this. I'm excited for us, hopefully, to continue work.

There are ideas that the microbiota might be affecting this, metabolomics. We're going to learn a lot.

This is great. We've hit on a lot of important topics, looking at patient-reported outcomes and the effect of work and loss of productivity for patients with IBD and fatigue. Thank you so much for spending time to talk with me about this.

Dr. Hudesman:  Thanks so much.