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Fight IBD flares without errors

Challenges in inpatient care for inflammatory bowel disease are common, and they include choosing the right medications to manage pain and knowing when to consult other clinicians.

Patients with inflammatory bowel disease (IBD) receive most of their care as outpatients, but many will be hospitalized at some point. When that happens, it's up to hospitalists working with IBD specialists and other team members to get to the bottom of the reason for admission and remedy it.

“Hospitalists take the brunt of [IBD] admissions nowadays,” said gastroenterologist and IBD researcher David G. Binion, MD, professor of medicine at the University of Pittsburgh School of Medicine. “We ask for consultants to be a part of these admissions, but [hospitalists are] the people who are oftentimes handling the day-to-day decision making and management.”

Unfortunately, challenges in IBD inpatient care are not uncommon. Managing pain with the wrong medications and failing to consult other clinicians are two of the most important errors to avoid, experts said. They offered tips on how hospitalists can steer clear of these pitfalls and improve care for patients with IBD.

Diagnosing destabilization

Patients with ulcerative colitis and Crohn's disease, the most common forms of IBD, may report that their admissions are due to a disease “flare.” But exactly what that means requires a bit of detective work, Dr. Binion said. “A flare to a patient basically means problems involving their abdomen and their GI tract, but ‘flare’ is probably best differentiated,” he said.

Most adults with ulcerative colitis whose disease flares make them sick enough to be hospitalized will have what is called severe or fulminant ulcerative colitis, said Christopher Charles Fain, DO, a gastroenterology-trained hospitalist and assistant professor of medicine at Johns Hopkins Medicine in Baltimore.

These patients will typically have more than six bowel movements per day (sometimes more than 10 or 20 per day) and will often have bloody stools, malaise, weight loss, low-grade fevers, and abdominal pain, he said. “Many of these patients will have already carried a diagnosis of ulcerative colitis, but for some it will be [a] new diagnosis,” said Dr. Fain.

Patients with Crohn's disease may also have colitis and become hospitalized due to dehydration and blood loss, according to KT Park, MD, MS, associate professor of pediatrics at Lucile Salter Packard Children's Hospital at Stanford in Palo Alto, Calif.

“Oftentimes, we associate severe ulcerative colitis as needing hospitalization, but Crohn's colitis, when severe, can have the same symptomatology,” he said.

But symptoms aren't always triggered by IBD itself, so it's important to diagnose the cause of destabilization, said Dr. Binion.

For example, Crohn's disease patients may describe a “flare” involving abdominal distention, crampy pain, and nausea/vomiting and be found to have partial small-bowel obstruction caused by inadequately chewed fibrous foods. “Then, if the partial obstruction is alleviated, they're magically better within 24 hours,” said Dr. Binion, adding that bowel rest and IV fluid support are often enough to treat these patients. “That may not be quite the same thing as a flare with colitis that could take literally weeks to months to bring under control.”

In patients reporting a flare of their underlying colitis, the culprit may be a bug that is all too familiar to hospitalists: Clostridium difficile. Since 2013, the American College of Gastroenterology has strongly recommended that all IBD patients hospitalized with a disease flare be tested for C. difficile. The infection creates an inflammation of the gastrointestinal (GI) tract that appears identical to a colitis-predominant IBD flare, Dr. Binion said, “but you can't tell it apart without doing the testing.”

C. difficile is the most commonly isolated stool pathogen in patients with IBD, said GI hospitalist Seth Sweetser, MD, who outlined staggering statistics in November at the Mayo Clinic Hospital Medicine 2017 conference in Tucson, Ariz. “If you have IBD, you're five times more likely to get C. diff, and 5% of all IBD patients develop it in the first five years of their IBD diagnosis,” he said. IBD patients with C. difficile also have longer lengths of stay, increased rates of colectomy, and higher mortality rates, said Dr. Sweetser, associate professor of medicine at Mayo Clinic in Rochester, Minn.

Acute management challenges

The prevalence of C. diff complicates treatment of IBD flares. IV steroids may be the cornerstone of colitis care, but “IV steroids and no therapy for C. diff is probably the worst thing we can do for an IBD patient who has C. diff infection,” said Dr. Binion. If an IBD patient turns out to have C. difficile infection, both issues need to be addressed. “We can't treat the infection in isolation; we actually have to treat both the infection as well as the underlying IBD flare that it has precipitated,” he said.

Oral vancomycin is considered first-line therapy for C. difficile in IBD patients, and fidaxomicin has emerged as an equally effective second agent, Dr. Binion said. “Metronidazole, which has been used as first-line therapy for many years, is not an adequate agent when it comes to IBD patients with C. diff,” he said. Although most C. diff treatment with vancomycin lasts for 10 to 14 days, IBD patients have a higher risk of recurrence than the general population and will likely warrant longer courses of therapy, Dr. Binion added.

No one wants to overuse antibiotics, but he recommended initiating treatment for C. diff as soon as it's suspected because the infection is associated with increased mortality in the IBD patient population. “One of the concerns I have is that people are waiting for a test result to get permission to treat when they're highly, highly suspicious about C. diff being the reason for that person to be sick enough to be hospitalized,” said Dr. Binion.

At the University of Pittsburgh, he has had success with an innovative approach. “When we lowered the steroid dosing by approximately 50% when we were suspicious for C. diff, and we initiated concomitant vancomycin therapy targeting C. diff . . . we saw a marked decrease in colectomies,” he said. Based on this institutional experience, Dr. Binion still uses this protocol 10 years later.

Other worries in IBD flare care include systemic bacterial infections. It's important to watch for tachycardia and pain as signs of worsening or sepsis, since immunosuppressed patients may not develop a fever, advised Sunanda V. Kane, MD, FACP, professor of medicine at Mayo Clinic in Rochester, Minn., and president-elect of the American College of Gastroenterology.

“It is OK to treat with steroids for the IBD in addition to antibiotics if there is documented infection,” she said. “It is uncontrolled [untreated] infection with steroids that gets people into trouble.”

Make sure that patients don't have disseminated infection before starting immunosuppressive treatment, agreed Dr. Park. “Yes, the patient most likely would benefit from corticosteroids sooner than later if it's an IBD flare, but particularly in new-onset diagnoses, you don't want to be starting corticosteroids without clinching the diagnosis, because that patient may just have disseminated infection,” he said.

On the other hand, you don't want to wait too long, since patients with severe ulcerative colitis will likely have better outcomes the sooner they receive steroids, said Dr. Fain. “One of the fears is that these patients could have C. diff infection, but studies indicate it is usually safe to start steroids in patients with severe ulcerative colitis complicated by C. diff infection, with the exception of those who have developed toxic megacolon,” he said.

Another challenge is determining the proper steroid dose. “One of the common mistakes made by the ED doctor or hospitalist is starting patients on much higher doses than what is needed for ulcerative colitis patients with a severe flare,” Dr. Fain said. The usual dosing range for IV methylprednisolone in such patients is 40 to 60 mg daily, often broken up into two or three 16- to 20-mg doses, he advised. Some patients are started on doses as high as 125 mg multiple times a day, “and that would be inappropriate for these patients,” said Dr. Fain.

Patients on IV steroids for a severe colitis flare should see dramatic improvement in GI symptoms and inflammatory markers within three days, experts agreed. “If a patient gets better on IV steroids, convert them to oral in the hospital and keep them at least through another two mealtimes to make sure they don't bounce back in,” Dr. Kane recommended.

If diarrhea hasn't improved after three days, she recommended checking for C. diff again, as the patient may have acquired it in the hospital. And if IV steroids do not lead to improvement, an anti-tumor necrosis factor (TNF) agent like infliximab may be used as a rescue approach, said Dr. Binion.

“The decision to use infliximab should be fairly quick, within 48 to 72 hours of admission,” he said. The drug is probably even preferable to IV steroids in IBD patients with C. diff infection, Dr. Binion added. “It doesn't have the profound, broad, suppressive effect on immune function, including antibody production, which is really essential for clearing C. diff,” he said.

Medication missteps and surgical solutions

Although helping patients to a quick recovery is the goal, too rapid of a discharge after conversion to oral steroids can send patients with IBD back to the hospital, said Dr. Kane. Another major reason for readmissions is pain management, she added.

ED visits, hospitalization, and surgery are often the first portals for long-term opioid use in patients with IBD, which is problematic for many reasons, said Dr. Park. “In patients with IBD, there seems to be an ever-increasing incidence of opioid addiction and dependency,” he said.

Opioid use in IBD patients is associated with 30-day readmissions, according to a 2017 study in PLoS One. Overall, IBD readmission rates are fairly low compared to other chronic conditions—about 7%, the study found.

That may be due to the youth of the patients compared to those with other chronic diseases, such as heart disease and liver disease, said lead author Dejan Micic, MD, a gastroenterologist and assistant professor of medicine at the University of Chicago Medical Center. Many patients with IBD are diagnosed in adolescence or young adulthood.

“There are two nodes of big incidence peaks, and that's usually around [ages] 10 to 15 and then again between 25 to 35,” noted Dr. Park.

At one tertiary care center, about 70% of 117 patients with IBD received opioids over the course of one year, a 2012 study in Inflammatory Bowel Diseases found. “I think that's the No. 1 overwhelmingly common mistake and pitfall because when a patient is dependent and needing that opioid, it just means that we need to address the acute inflammation and not try to mask the pain,” said Dr. Park.

Gastroenterologist Stephen B. Hanauer, MD, FACP, professor of medicine at Northwestern University Feinberg School of Medicine in Chicago, gives hospitalists two explicit recommendations on pain management: no narcotics and no NSAIDs. “In our practice and in most sophisticated GI practices, we do not give opioids.” Use acetaminophen or tramadol instead, he said.

Anti-anxiety medications can also help with cramping and sleep, experts said. “I sometimes offer patients benzodiazepine compounds, such as lorazepam, to help with sleep because nighttime is the worst in terms of being up every few hours to go to the bathroom,” said Dr. Binion.

For Crohn's disease patients, pain relief may be possible with nothing at all. “If a Crohn's patient has pain with eating, don't give them food. . . you are just working against yourself,” said Dr. Kane. Patients with ulcerative colitis, however, do not need to be made NPO unless they are going for urgent surgery or a sedated procedure, she said.

In addition to avoiding opioids, be sure to withhold antidiarrheals in patients with ulcerative colitis, Dr. Fain said. “These medications can slow the digestive tract and could theoretically cause toxic megacolon in these sick patients,” he said.

At some point in their disease course, many people with IBD will need to have surgical resection of refractory bowel segments, Dr. Hanauer said. “About 80% of patients with Crohn's disease at some point in their life are going to need surgery,” he said. “In ulcerative colitis, it's less. It's only about 20%.”

Intestinal resection was once the only effective treatment for Crohn's disease. Now, with multiple medical management options, “the ultimate therapeutic goal in [Crohn's disease] should be to reduce the long-term risk for intestinal resection,” researchers wrote in Gut in 2011. The risks of surgery include hemorrhage, reduced female fertility, erectile and sexual dysfunction, infection, and fistulas, according to a review published in 2012 by Clinical Gastroenterology and Hepatology.

However, resection can improve long-term outcomes in IBD patients. Dr. Micic's study, for example, found that surgery was actually associated with a lower risk of readmission, particularly in patients with Crohn's disease. “Surgery is not necessarily what we're trying to avoid in IBD anymore,” he said. “Getting the input of a surgeon for an IBD patient is essential to prevent emergent surgeries and to allow the patient to understand the risks and benefits of surgery for their condition.”

Patients with Crohn's can usually have surgery as outpatients unless there is nonresolving obstruction or frank perforation, but ulcerative colitis patients often need attention from surgeons during an admission, said Dr. Kane. “A surgeon always wants to know about a possible case sooner rather than after five days after no response to steroids,” she said.

At Johns Hopkins, a colorectal surgeon is usually involved within the first 24 hours for colitis patients having a severe flare. Such patients may need to decide between a medical approach or surgical approach, such as an ileal pouch-anal anastomosis, to treat their disease.

Dr. Fain tells patients that the ileal pouch-anal anastomosis procedure will likely drastically improve their symptoms, although many will still have loose stools. He also lets women know that as many as one-third could have fertility problems after the procedure.

Collaborative care

Hospitalists also need to know when to consult gastroenterology, which the experts said often does not happen early enough. “A hospitalist should be working with a gastroenterologist from day one when a hospitalized patient is suspected or confirmed to have Crohn's disease or ulcerative colitis,” said Dr. Park.

In the acute stage of a flare, a hospitalist's main role is in the short-term assessment and treatment of the flare and any complications, such as abscesses, perforations, bowel obstructions, and diarrhea, as well as keeping on top of hydration and nutrition, Dr. Hanauer said. “They need to be adept at the things they are adept at, which is treating the complications rather than the underlying disease,” he said.

Once an IBD patient has recovered from a flare and is preparing to transition out of the hospital, it's the gastroenterologist's turn to take the lead and chart the long-term therapeutic approach, Dr. Hanauer said.

However, Dr. Park believes high-value IBD care should include collaboration between the hospitalist and gastroenterologist to individualize a patient's discharge plan and transition from corticosteroids to maintenance therapy. “The hospitalist has to think about not only the acute episode, but also necessary care coordination for the patient to stay out of the hospital,” he said, adding that it would be a mistake for a hospitalist to rely on corticosteroids to “cool the fire” without bothering to understand what the long-term therapy plan will be.

Comanagement is especially important at discharge, agreed Dr. Fain. “IBD patients will need long-term management of these chronic disease processes, and ideally, most patients will follow up with a gastroenterologist a week or two after discharge to prevent early readmission and to ensure ongoing medical progress,” he said.

Dr. Micic added that gastroenterologists and hospitalists should work together to try to identify and act on readmission risk factors. He anticipates that, ultimately, electronic health records will identify patients at high risk for readmission. “As long as it's an accurate flag, then there could be even more communication between the hospitalists and gastroenterologists for discharge planning to include early appointments or the creation of a postdischarge clinic aimed at mitigating the readmission risk,” he said.