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Case A. - 42 yr old male patient

Treatment of Extra-intestinal Manifestations of IBD: Case studies Alan C. Moss MD, FEBG, FACG Associate Professor of Medicine Director of Translational Research. Case A. - 42 yr old male patient. Left-sided ulcerative colitis for 4 years In clinical remission on mesalamine 4.8g/day

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Case A. - 42 yr old male patient

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  1. Treatment of Extra-intestinal Manifestations of IBD: Case studies Alan C. Moss MD, FEBG, FACGAssociate Professor of MedicineDirector of Translational Research

  2. Case A. - 42 yr old male patient • Left-sided ulcerative colitis for 4 years • In clinical remission on mesalamine 4.8g/day • Admitted for flare-up January 2013 – Rx IV steroids and discharged on PO prednisone taper • Clinic follow-up – slow to taper off prednisone, azathioprine added, tolerated well • Seen in office visit complaining of fatigue; started on oral ferrous sulfate 100mg by primary care physician

  3. Trend in Hematologic Indices Hematocrit (40-50%) Iron Profile

  4. What would you do next? • Increase oral iron dose • Blood transfusion • Iron infusion • Erythropoietin • All of the above

  5. Causes of Anemia in IBD Iron Deficiency Chronic Disease Bone marrow suppression Drug-induced hemolysis Vitamin B12 / folic acid deficiency 20% of Out-patients 60% of Hospitalized patients Gisbert J, Am J Gastroenterol. 2008 May;103(5):1299-307.

  6. Determining Iron Deficiency in IBD Gasche C, Inflamm Bowel Dis 2007;13:1545-1553

  7. Oral OR IV Iron for Iron Deficiency in IBD

  8. Meta-Analysis of Trials to Date • Hb rise >2g/dl - RR of 0.98, 95% (CI 0.9, 1.1) p=0.7 • Mean change in Hb (g/dl) - 0.7 96% (CI 0.3, 1.7) p=0.1 • Increase in serum ferritin - 84, 95% (CI 79, 92) p>0.001 • Risk of withdrawal due to adverse events RR 2.7 (CI 1.4, 5.2) p=0.002 Abhyankar, Moss submitted to DDW 2014

  9. Erythropoietin for Anemia in IBD Schreiber s N Engl J Med. 1996 Mar 7;334(10):619-23

  10. Guidelines – ECCO 2013 • “Iron supplementation should be initiated when iron deficiency anemia is present, and considered when there is iron deficiency without anemia • Intravenous iron is more effective and better tolerated than oral iron supplements • Absolute indications for intravenous iron include severe anemia (hemoglobin < 10.0 g/dL), and intolerance or inadequate response to oral iron • Intravenous iron should be considered in combination with an erythropoietic agent in selected cases where a rapid response is required” Van Asche G, J Crohns Colitis. 2013 Feb;7(1):1-33

  11. Case B. - 59 year old male Colonic Crohn’s for 20 years Developed lymphoma while on azathioprine Recent flare-up; 4-6 BM per day, cramps Rx budesonide & metronidazole Call from PCP – in local ED with frank rectal bleeding, and swollen left leg Ultrasound – left leg Deep Venous Thrombosis (DVT)

  12. Sigmoidoscopy

  13. What would you suggest next? • Low Molecular Weight Heparin • Unfractionated Heparin • Vena caval filter • Other

  14. Venous Thromboembolism in IBD – A ‘Preventable Complication’ • 1-2% of all IBD hospitalizations • Out-patients have 8-fold higher risk of VTE during flares, than when in remission • Risks: age, UC, surgery, smoking, oral contraceptives • Less than 40% of GIs ‘always’ prescribe VTE prophylaxis Nyugen G. Am J Gastroenterol. 2008 Sep;103(9):2272-80; Grainge MJ, Lancet. 2010 Feb 20;375(9715):657-63 Razik R, Can J Gastroenterol. 2012 Nov;26(11):795-8

  15. VTE Prophylaxis is Under-Utilized in IBD ‘All’ ‘None’ Actual administration of ordered doses by nurses Number of hospital days with VTE prophylaxis ordered Pleet J et al , DDW 2013, S434

  16. VTE Prevention in IBD • AGA Physician Performance Measures Set 2011; ‘Measure # 9: Patients with IBD receive prophylaxis for venous thromboembolism during hospitalization for any reason.’ • LMW / UF heparin • Compression stockings • Minimizing IV catheter use • Address smoking, OCP use, immobility • ?Out-patient flares also

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