I wanted to share some notes from the Atlanta CCFA “Update in Inflammatory Bowel Disease” conference which was held March 23, 2013.
The first talk by Gil Melmed reviewed immunization issues in IBD. One of the best quotes of the conference was on his first slide: “The single most important thing a [rheumatologist] can do to optimize care for a [lupus] patient is to act as their internist, yet that is the last thing most [rheumatologists] wish to or feel qualified to do.” (Wallace DJ. Lupus 2008 (17) 91-2.
While trying to manage all aspects of the health care of our patients with chronic disease is an ideal, he also noted that 20-30% of adult IBD doctors do not understand the importance of avoiding live-virus vaccines (a list of these are noted in previous blog: Protecting the most vulnerable | gutsandgrowth).
One of the take-home points from this talk for me was to avoid use of rotavirus vaccine in newborn patients if their mother is receiving Infliximab or Adalimumab. Another useful point would be to remind family members of immunosuppressed IBD patients to receive the influenza vaccine rather than the live-virus vaccine (flumist).
The second talk by Wallace Crandall focused on improving health care delivery. The best quote of the day was from his first slide: “Every system is perfectly designed to achieve exactly the results it gets.” (Donald Berwick). One of his slides that I found intriguing showed 2007 data on immunomodulator use within the first 3 months of diagnosis from 10 different centers. The rate varied from 30% to 98%. He didn’t try to answer how frequent immunomodulator use in this time period should occur but there was no valid reason for this degree of variation.
In Columbus (Ohio), he stated that they are working to transform chronic care from 15-30 minute visits every 3-6 months to a more continuous process. “Patients receive only 60% of recommended care.” With a better health care delivery system, this could be improved and potentially improve outcomes.
Another obstacle is the lack of evidence to guide decisions. Recent “ECCO” guidelines for pediatric ulcerative colitis had 48% of recommendations based on level D evidence.
The third talk by Douglas Drossman was probably the most helpful. He discussed pain management in IBD. He reviewed a lot of recent data on irritable bowel syndrome (IBS) and discussed similarities between post-infectious IBS and many patients with treated IBD.
He also discussed central pain aspects and alluded to changes in the brain that happen with chronic treatment (Pain changes brain | gutsandgrowth). He noted that antidepressants have the potential to reverse brain changes due to chronic pain but that regrowth of neurons can take a long time. As such, he noted that agents like imipramine are needed for at least one year. Use of imipramine, he noted, has been shown to improve cognitive function in mice with traumatic brain injury (J Neurotrauma 2011; 28: 995).
With regard to IBD, Dr. Drossman noted a wide variability in pain response among patients. Some who have very significant mucosal disease do not experience significant pain, likely due to downregulation of some central pathways. He outlined his treatment model for pain in IBD.
- Effective communication improves clinical outcomes
- Just as there is a “treatment pyramid” for IBD, with IBS the treatment pyramid ncludes the following: motility agents, antispasmodics, antidepressants, psychological intervention, and central augmentation.
- With regard to antidepressants, he highlighted the differences between tricyclics, SSRIs, and SNRIs. He noted that SSRIs like citalopram, escitalopram, fluoxetine, paroxetine, and sertraline are not effective at reducing pain but can help anxiety/depression.
- Tricyclic antidepressants are effective at reducing pain and are inexpensive. Side effects can include sedation, dry mouth, dizziness, and constipation. Desipramine and nortriptyline have fewer side effects.
- SNRIs including duloxetine, venlafaxine, desvenlafaxine, and minacipran are effective at reducing pain and fewer side effects. However, they are considerably more expensive. Nausea, though, is not infrequent.
- Psychologic treatments: cognitive behavioral, psychotherapy, hypnosis, and relaxation training. When to refer? moderate-severe symptoms, maladaptive coping (eg. “catastrophizing”), and motivated patient.
- What is central augmentation? If an antidepressant is not effective, augmentation is adding an agent that may target a different brain receptor. Potential augmenters include pharmacologic and non-pharmacologic approaches. Pharmacologics could include added gabapentin, added atypical antipsychotic (e.g.. quetiapine [Ability]), added clonidine, added buspirone, or added mirtazepine (e.g. remeron). Most practitioners will need the help of a psychiatrist to manage these medications.