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IBD: A Comorbidity of PSC

IBD: A Comorbidity of PSC. Laura Raffals, MD, MS. The Spectrum of IBD 1.6 Million Americans. ULCERATIVE COLITIS Continuous inflammation Colon only Superficial inflammation Variable involvement Risk of cancer Strictures (cancer) Extraintestinal manifestations. CROHN ’ S DISEASE

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IBD: A Comorbidity of PSC

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  1. IBD: A Comorbidity of PSC Laura Raffals, MD, MS

  2. The Spectrum of IBD1.6 Million Americans • ULCERATIVE COLITIS • Continuous inflammation • Colon only • Superficial inflammation • Variable involvement • Risk of cancer • Strictures (cancer) • Extraintestinal manifestations • CROHN’S DISEASE • Patchy inflammation • Mouth to anus involvement • Full-thickness inflammation • Variable involvement • Fistulas • Strictures • Extraintestinal manifestations Indeterminate colitis10-15%

  3. Temporal Trend in the Incidence of Crohn’s Disease in Olmsted County, 1940-2004 Ingle SB, et al. Gastroenterology 2007 Suppl

  4. Temporal Trend in the Incidence of Ulcerative Colitis in Olmsted County, 1940-2004 Ingle SB, et al. Gastroenterology 2007 Suppl

  5. Changing Geographic Distribution of IBD 1950 2000

  6. Immune Response IBD Geneticsusceptibility Environmentaltriggers Pathogenesis of IBD CP1169260-9

  7. Disease Extent • Crohn’s can involve any part of GI track • But colon alone in 20-30% • UC involves only the colon • But “backwash ileitis” in 7-15% • PSC-IBD • Is this its own entity?

  8. Anatomic Distribution of CD Upper gut < 10% Small bowel alone 33% Ileocolonic 45% Colon alone 20%

  9. CD: Clinical Patterns Fibrostenotic Inflammatory Fistulizing

  10. CD: Clinical Patterns Fistulae and Abscesses

  11. Anatomic Extent of UC Left-Sided Colitis Pancolitis Procto- sigmoiditis

  12. PSC-IBD

  13. PSC & IBD • 70% of PSC patients have IBD • 80% UC • 10% CD • 10% Indeterminate • 5% of IBD patients have PSC • All IBD patients should have liver enzymes tested annually

  14. PSC-IBD • PSC-IBD is a unique entity • Relatively quiescent disease • Increased risk for colorectal cancer • IBD usually precedes PSC diagnosis (median 10 years) • PSC can develop after colectomy

  15. PSC-IBD Characteristics • UC • Pancolitis • Rectal sparing and backwash ileitis • Right side > left side • CD • Often ileocolonic • Isolated small bowel disease is rare • Fibrostenotic and penetrating complications are rare • Are these often mischaracterized PSC-IBD patients?

  16. PSC-IBDRelationship between colectomy and PSC • Early colectomy is associated with decreased risk for future liver transplantation • Colectomy prior to liver transplant associated with lower risk for recurrent PSC • IBD disease activity NOT associated with risk of recurrent PSC after liver transplant

  17. What is the link between IBD & PSC • We don’t know • Bile acids • “Leaky gut” • Gut dysbiosis • Lymphocyte homing • Genetics

  18. Risk of colorectal cancer in PSC • Risk of CRC is higher in IBD compared to general population • Patients with PSC-IBD at greater risk of CRC compared to IBD alone • Pancolitis and inflammation are additional risk factors for CRC

  19. CRC screening guidelines • Colonoscopy should be done in all patients at time of PSC diagnosis if no history of IBD • If no colitis, continue colonoscopies every 3-5 years • In patients with PSC-IBD, annual colonoscopy • Chromoendoscopy • Colectomy is recommended if CRC or high grade dysplasia

  20. IBD Treatment

  21. Cure Mucosal Healing Reduction in Hospitalizations and Surgeries Maintenance of Steroid-Free Remission Induction of Remission Alleviate Symptoms Treatment goals in IBD in 2019 are rapidly evolving Changing The Natural History of Disease?

  22. Improved Clinical Outcomes Have Coincided With The Expanding IBD Therapeutic Armamentarium Danese S, Vuitton L, Peyrin-Biroulet L. Nat Rev GastroenterolHepatol 2015;12:537-45

  23. Treatment categories

  24. Better Treatment StrategiesAre Essential for Improving Clinical Outcomes 1. Early intervention

  25. The Window of Opportunity for Early Intervention in IBD Stricture Surgery Intestinal damage Disability Inflammatoryactivity(CDAI, CDEIS, CRP) Fistula/abscess Stricture Windowofopportunity? Diagnosis Diseaseonset Earlydisease CDAI, Crohn'sdiseaseactivity index; CDEIS, Crohn’sdiseaseendoscopic index of severity; CRP, C-reactiveprotein Pariente B, et al. InflammBowel Dis 2011;17:1415–22

  26. New Treatment Goals - Blocking Disease Progression and Preventing Damage and Disability Intestinal damage Disability Inflammatoryactivity(CDAI, CDEIS, CRP) Diagnosis Diseaseonset Earlydisease CDAI, Crohn'sdiseaseactivity index; CDEIS, Crohn’sdiseaseendoscopic index of severity; CRP, C-reactiveprotein Pariente B, et al. InflammBowel Dis 2011;17:1415–22

  27. Better Treatment StrategiesAre Essential for Improving Clinical Outcomes 1. Early intervention 2. Individualized treatment

  28. Predicting the course of disease: • Treatment goals individualized based on disease activity & severity, patient goals and risks • We can’t undo the past • We can impact the future Defining the likely course of disease Disease activity: How is the patient now? PROs & objective markers Disease severity: What has been the patient’s disease course?

  29. New Paradigm: Treating beyond symptoms Symptom severity Step-up approach Top-down approach

  30. Better Treatment StrategiesAre Essential for Improving Clinical Outcomes 1. Early intervention 2. Individualized treatment 3. Treat to target 4. Tight control monitoring

  31. Evolving goals of therapy for IBD: sustained deep remission Goal Clinical parameters Outcomes Response Improved symptoms Improved QoL No symptoms Decreased hospitalization Remission Normal labs Normal endoscopy Avoidance of surgery Deep remission Mucosal healing Minimal/no disability SUSTAINED DISEASE CONTROL

  32. Therapeutic Decision Making in IBD is Individualized in Every Patient RISKS OF UNDER- TREATMENT RISKS OF OVER- TREATMENT • Infections • Lymphoma • Other rare AEs • Cost • Corticosteroid exposure • Complications - Fibrostenosis / Penetrating • Hospitalizations and surgeries • Colorectal cancer • Disability / Absenteeism • Reduced QOL

  33. Balancing Risk of Disease & Risk of Treatment

  34. Putting risk in perspective Odds of Dying, National Safety Council. Available at: http://www.nsc.org/lrs/statinfo/odds.htm. Accessed 2015.

  35. Risk of Developing non-Hodgkin’s Lymphoma Patient receiving Immunomodulator +/- anti-TNF Therapy for 1 year Risk without medication Risk of lymphoma with immune suppression Siegel CA, Inflamm Bowel Dis 2010;16:2168.

  36. Preventive Care • IBD patients do not receive preventive services at same rate as general medical patients • IBD patients on immunomodulators or biologics have unique needs • Vaccinations • Screening for osteoporosis • Cervical cancer • Skin cancer • Depression/anxiety • Smoking cessation Farraye F, et al. American Journal of Gastroenterology. 112(2):241–258, FEB 2017

  37. Inactive vaccine recommendations Farraye F, et al. American Journal of Gastroenterology. 112(2):241–258, FEB 2017

  38. Quinn et al. “Impact of a Multidisciplinary eBoard for Management of Complex IBD”, presented at Crohn’s Colitis Congress 2019 Multidisciplinary approach – the best care for all Behavioral health Radiology & Pathology Primary care Specialists IBD center Surgeons Hepatologists

  39. Questions & Discussionraffals.laura@mayo.edu

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