Download - Case A. - 42 yr old male patient
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Treatment of Extra-intestinal Manifestations of IBD: Case studies
Alan C. Moss MD, FEBG, FACG
Associate Professor of MedicineDirector of Translational Research
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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
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Trend in Hematologic Indices
Hematocrit (40-50%) Iron Profile
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What would you do next?
A. Increase oral iron dose
B. Blood transfusion
C. Iron infusion
D. Erythropoietin
E. All of the above
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Causes of Anemia in IBD
Iron Deficiency Chronic
Disease
Bone marrow suppressionDrug-induced hemolysis
Vitamin B12 / folic acid deficiency
Gisbert J, Am J Gastroenterol. 2008 May;103(5):1299-307.
20% of Out-patients60% of Hospitalized patients
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Determining Iron Deficiency in IBD
Gasche C, Inflamm Bowel Dis 2007;13:1545-1553
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Oral OR IV Iron for Iron Deficiency in IBD
Study Comparisons
Reinisch 2013 PO FeSO4 200mg v IV iron isomaltoside
Schroder 2005 PO FeSO4 200mg v IV iron sucrose
Gisbert 2009 PO FeSO4 v IV iron sucrose
Lindgren S 2009 PO FeSO4 v IV iron sucrose
Kulnigg 2008 PO FeSO4 200mg v IV ferric carboxymaltose
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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
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Erythropoietin for Anemia in IBD
Schreiber s N Engl J Med. 1996 Mar 7;334(10):619-23
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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
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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)
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Sigmoidoscopy
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What would you suggest next?
A. Low Molecular Weight Heparin
B. Unfractionated Heparin
C. Vena caval filter
D. Other
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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
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VTE Prophylaxis is Under-Utilized in IBD
Pleet J et al , DDW 2013, S434
Number of hospital days with VTE prophylaxis ordered
‘None’‘All’
Actual administration of ordered doses by nurses
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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