Updated ESPGHAN Percutaneous Endoscopic Gastrostomy Position Paper

M Homan et al. JPGN 2021; 73: 415-426. Open Access: Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper

A couple of interesting recommendations in this updated position paper on the use of percutaneous endoscopic gastrostomy (PEG) include the following:

  • Feeding can be initiated as early as 3 hours post-procedure in a stable child with no complications.
  • Iso-osmolar feeds of the standard polymeric formula are the best type of food to start with after the PEG insertion” and ” bolus feeding is more physiological and should be the first choice… in some children, small boluses during the day could be combined with the overnight continuous feeding via enteral pump.”
  • Replacing the initial tube with a gastric balloon/button should be recommended to the families/children who will need long term enteral nutrition to improve quality of life.”
  • Gastric balloons should be replaced every 6 months, but non-balloon PEGs can be replaced annually.”

The full article provides a rationale/nuance for these recommendations. Use of feeds starting at 3 hrs post-op has been found to be safe. And, there is no evidence available that suggests routine use of a clear fluid test or dilute or hypotonic feed after the procedure. In fact, it has been suggested that these measures delay the time to full enteral intake and prolong hospital stay.

With regard to balloon button Gtube changes, the authors note that while manufacturers recommend changing every 3 months, “in the majority, these are safe to replace less frequently.”

The authors clearly favor low-profile buttons and state that changing to them earlier after initial Gtube placement (after 1 month) under general anesthesia should be safe (if no issues with healing like diabetes, and systemic corticosteroids); “however, the physician should give the parents/child the possibility of choice whether to perform the replacement or not.” Also, “the primary device can stay in place for one year or even more. In a German study, 85% of parents answered that the GB is advantageous over primary gastrostomy tube due to mobility, patient comfort at physiotherapy, swimming or night-time sleep, and higher parent satisfaction.”

My take: This article provides a good summary of PEG indications/contraindications, complications, and advise for clinicians

Related blog posts:

Resource:

www.feedingtubeawareness.com  This site contains a terrific PDF download which explains enteral tubes in an easy to understand style along with good graphics. “What You Need to Know Now, A Parent’s Introduction to Tube Feeding is the guidebook that every parent wished they had when they were first introduced to feeding tubes.”

Shelburne Farms, VT

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Expert Consensus: New Recommendations for Therapeutic Drug Monitoring

AS Cheifetz et al. Am J Gastroenterol 2021;00:1–12. A Comprehensive Literature Review and Expert Consensus Statement on Therapeutic Drug Monitoring of Biologics in Inflammatory Bowel Disease (published online August 13, 2021)

Key recommendations:

  • The panel agreed that reactive TDM should be used for all biologics for both primary nonresponse and secondary loss of response
  • It was recommended that treatment discontinuation should not be considered for infliximab or adalimumab until a drug concentration of at least 10–15 mg/mL was achieved
  • Consensus was also achieved regarding the utility of proactive TDM for anti–tumor necrosis factor therapy. It was recommended to perform proactive TDM after induction and at least once during maintenance.
  • More data are needed with regard to proactive TDM for biologics other than anti-TNF agents
  • There are no differences in interpreting TDM between originator biologics and biosimilars
  • When considering switching within drug class in case of secondary loss of response to a first anti-TNF drug because of the development of antidrug antibodies, an immunomodulator should be added to a subsequent anti-TNF therapy
  • Low-titer antidrug antibodies can be overcome by treatment optimization (dose escalation, dose interval shortening, and/or addition of an immunomodulator)

My take: This article should help support the practice of proactive TDM and discourage stopping anti-TNF agents until an adequate therapeutic level is achieved.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Secondary Prophylaxis of Clostridiodes difficile Infection

H Bao et al. Pediatrics 2021; 148: e2020031807. Oral Vancomycin as Secondary Prophylaxis for Clostridioides difficile Infection. Thanks to Ben Gold for sharing this reference.

Methods: A multicampus, retrospective cohort evaluation was conducted among patients aged ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter from 2013–2019. This study identified 30 and 44 patients received oral vancomycin prophylaxis (OVP) and no OVP, respectively. Eligible patients had to be >12 months of age and having at 3 unformed stools everyday.

OVP dosing: “vancomycin doses of 10 mg/kg (up to 125 mg per dose) every 12 hours during concomitant antibiotic use. OVP duration was intended to continue while on systemic antimicrobial agents and for 5 days after completion of antimicrobial agents (extended prophylaxis tail), but practice varied, and duration was ultimately left to the discretion of the provider.”

Key finding:

The incidence of CDI recurrence within 8 weeks of antibiotic exposure was significantly lower in patients who received OVP (3% vs 25%P = .02) despite this group having notably more risk factors for recurrence.   After adjustment in a multivariable analysis, secondary OVP was associated with less risk of recurrence (odds ratio, 0.10; 95% confidence interval, 0.01–0.86; P = .04).

This study is in agreement with studies in adults (Brown CC, et al. Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection. Ann Pharmacother. 2019 Apr;53(4):396-401). In this review, the authors state: “Variable dosing regimens and lack of safety data are limitations.. clinicians can consider vancomycin 125 mg orally once or twice daily in high-risk patients receiving broad-spectrum antibacterial agents.”

My take: In patients at high risk of recurrent CDI, OVP should be considered as secondary prophylaxis when receiving systemic antibiotics.

Related blog posts:

Tortuous Path to Watersound Beach, FL

‘Dual Immunotherapy’ for IBD

A recent study (MT Dolinger et al. Inflamm Bowel Dis 2021; 27: 1210-1214) and the associated editorial (D Geem, S Kugathasan. Inflamm Bowel Dis 2021; 27: 1361-1362) describe the use of multiple therapies (biologics and small molecule therapy) to target refractory pediatric inflammatory bowel disease. Since the term “combination therapy” is already in broad use for those receiving a biologic agent and an immunomodulator, I plan to refer to these new combinations as ‘dual immunotherapy’ for IBD.

Dolinger et al (Dual Biologic and Small Molecule Therapy for the Treatment of Refractory Pediatric Inflammatory Bowel Disease) described 16 children with dual immunotherapy. Nine (56%) were treated with vedolizumab/tofacitinib, 4 (25%) with ustekinumab/vedolizumab, and 3 (19%) with ustekinumab/tofacitinib. Twelve (75%; 7 ulcerative colitis/IBD-unspecified, 5 Crohn’s disease ) achieved steroid-free remission at 6 months. One patient on 30 mg of vedolizumab/tofacitinib and prednisone daily developed septic arthritis and a deep vein thrombosis.

In the editorial (It Takes Two to Make It Right: Dual Biologic and Small Molecule Therapy for Treatment-Refractory Pediatric Inflammatory Bowel Disease), Geem et al make a number of key points:

  • Except for “anti-TNF medications (infliximab and adalimumab), no other biologic therapies are FDA-approved for children with IBD”
  • “Clinical disease remission is achieved in only 40-60% of patients on anti-TNF medications”
  • With ustekinumab, “limited pediatric data reveal that in patients who have failed at least 1 biologic therapy, 38.6-58% achieve clinical remission by week 52…[And] vedolizumab …demonstrated steroid-free remission in 20% by week 22 in a single-center prospective observational cohort study.”
  • The response to dual immunotherapy is most likely due to the synergistic effects of two medications rather than the start of a new medication. The authors note a prior study which showed a positive experience of adding ustekinumab in 5 children who developed severe paradoxical psoriasis with infliximab and in another subset of pediatric patients, there was improvement with combination vedolizumab/infliximab (Paediatr Drugs 2020; 22: 409-416)

My take (borrowed from editorial): “Given the phenotypic heterogeneity of pediatric IBD and the multiple inflammatory immune pathways implicated in its pathogenesis, the approach of biologic monotherapy–may not be suitable for all patients…patients may require specific combinations…to quell multiple arms of their dysregulated immune response.” More trials are needed to determine the safety of these regimens (especially with regard to malignancy and infections).

Burlington VT (Lake Champlain)

Celiac Advocacy: Food Labeling Modernization Act

Gluten-Free Watchdog: Let’s Make Some Noise! Everything you need to contact your members of Congress asking them to support the Food Labeling Modernization Act of 2021

There are multiple ways to reach out to representatives and senators. Choose whatever method works best for you–mail, email, phone call, or in-person. Below is some information to help make the process easier.

  • Find representatives HERE.
  • Find senators HERE.
  • Sample phone scripts and letters noted on webpage link

More information from Celiac Disease Foundation: Food Labeling Modernization Act of 2021 – Marilyn’s Message August 2021

“On August 3, 2021, the Food Labeling Modernization Act (FLMA) of 2021 (H.R.4917 and S.2594) was introduced by House Energy and Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), House Appropriations Committee Chairwoman Rosa DeLauro (D-CT), and Senators Richard Blumenthal (D-CT), Sheldon Whitehouse (D-RI) and Ed Markey (D-MA). This legislation would update front-of-package food labeling requirements, require updates to the ingredients list on packaged foods, and apply consumer friendly labeling requirements, including the disclosure of gluten-containing grains...

As we know from the FDA’s Gluten-Free Labeling rule, food labels play an important role in managing celiac disease, yet federal labeling rules still do not require that food ingedients disclose if they containing barley or rye. This labeling change will allow concerned consumers to know, for example, if the malt syrup or natural flavorings in their food contains barley.

Food labels need to provide the simple, straightforward information that celiac patients need to evaluate products and make healthy choices.

Please take one minute to email your Members of Congress to support the Food Labeling Modernization Act of 2021 to make it easier and safer for individuals with celiac disease or gluten sensitivity to purchase food items by disclosing if foods contain gluten.”

IBD Shorts: Tofacitinib Safety, Vit D post-op, EIM with Vedolizumab

P Deepak et al. Clin Gastroenterol Hepatol 2021; 19: 1592-1601. Full Text: Safety of Tofacitinib in a Real-World Cohort of Patients With Ulcerative Colitis

This study described a ‘real-world’ experience with tofacitinib for Ulcerative Colitis in 260 adults; five patients developed HZ infection and 2 developed VTE (all receiving 10 mg tofacitinib, twice per day).

Related blog posts -Tofacitinib:

JR de Bruyn et al. Clin Gastroenterol Hepatol 2021; 19: 1573-1582. Full Text: High-Dose Vitamin D Does Not Prevent Postoperative Recurrence of Crohn’s Disease in a Randomized Placebo-Controlled Trial

Methods: Patients with CD after ileocolonic resection with ileocolonic anastomosis were assigned randomly to groups given weekly 25,000 IU oral vitamin D (n = 72) or placebo (n = 71) for 26 weeks, at 17 hospitals in The Netherlands and Belgium, from February 2014 through June 2017

Key finding: The cumulative rate of clinical recurrence did not differ significantly between the groups (18.1% in the vitamin D group vs 18.3% in the placebo group; P = .91). Though, the Vit D group achieved higher levels at week 26 (81 vs 43 of 25-OH Vit D)


GP Ramos et al. Inflamm Bowel Dis 2021; 27: 1270-1276. The Impact of Vedolizumab on Pre-Existing Extraintestinal Manifestations of Inflammatory Bowel Disease: A Multicenter Study

Key findings (n=201, retrospective study):

  • Worsening of EIMs after VDZ occurred in 34.8% of patients
  • Peripheral arthritis (PA) (68.2%) was most common EIM
  • Treatment using VDZ was discontinued specifically because of EIMs in 9.5% of patients

Related blog post: Vedolizumab and Extraintestinal Manifestations of IBD

Predicting IBD Outcomes –New Tools

In an observational prospective longitudinal study of with newly diagnosed Crohn’s disease in 156 adults followed for nearly 1.5 years, Yanai et al found that 52 patients (33.3%) had an indolent course of CD, 29 (18.5%) required hospitalizations, and 75 (48%) were recommended to start steroid, immunomodulator, or biologic therapies. An “indolent course” indicated a lack of needing steroids, immunomodulators, anti-TNF agents, hospitalization or surgery.  Key findings:

  • There were 4 factors associated with complicated course in treatment-naïve patients: body mass index <25 kg/m2 (hazard ratio [HR], 2.45; 95% CI, 1.07–5.43; P = .033), serum level of vitamin B12 <350 pg/mL (HR, 2.78; 95% CI, 1.21–6.41; P = .016), white blood cells ≥7 × 103/μL (HR, 2.419; 95% CI, 1.026–5.703; P = .044), and serum level of ALT ≥25 IU/L (HR, 2.680; 95% CI, 1.186–6.058; P = .018).
  • This model discriminated between patients with vs without a complicated course of disease with 90% and 89% accuracy at 6 and 12 months after diagnosis, respectively. A validation cohort demonstrated a discriminatory ability of 79% at 3 months after diagnosis, and a nomogram was constructed (see below)
Points on the nomogram are based on: BMI <25 kg/m2 = 87 or ≥25 kg/m2 = 0, WBC <7 × 103/μL = 0 or ≥7 × 103/μL = 83, vitamin B12 <350 pg/mL = 100 or ≥350 pg/mL = 0, and ALT <25 IU/L = 0 or ≥25 IU/L = 76. The sum score for all variables corresponds with the probability of having an indolent course of disease at different time points after diagnosis.

My take: In this study, low BMI, low Vit B12, high wbc, and high ALT were associated with a more complicated course. These particularly risk factors do not seem intuitive to me. These findings need to be looked at in the pediatric age group, which likely has a lower rate of an indolent course.

G Le Baut et al. Clin Gastroenterol Hepatol 2021; 19: 1602-1610. A Scoring System to Determine Patients’ Risk of Colectomy Within 1 Year After Hospital Admission for Acute Severe Ulcerative Colitis

In this retrospective study of 270 consecutive adult patients with acute severe ulcerative colitis (ASUC) (2002-2017), the cumulative risk of colectomy was 12.3% (95% CI, 8.6–16.8). Key findings:

  • Based on multivariate analysis, previous treatment with TNF antagonists or thiopurines (hazard ratio [HR], 3.86), Clostridioides difficile infection (HR, 3.73), serum level of C-reactive protein above 3.0 mg/dL (HR, 3.06), and serum level of albumin below 3.0 g/dL (HR, 2.67) were associated with increased risk of colectomy
  • The cumulative risks of colectomy within 1 y in patients with scores of 0, 1, 2, 3, or 4 were 0.0%, 9.4% (95% CI, 4.3%–16.7%), 10.6% (95% CI, 5.6%–17.4%), 51.2% (95% CI, 26.6%–71.3%), and 100%. Negative predictive values ranged from 87% (95% CI, 82%–91%) to 92% (95% CI, 88%–95.0%). Findings from the validation cohort were consistent with findings from the derivation cohort.

My take: These findings confirm other studies in patients with ulcerative colitis which have shown that each of these criteria were predictors of severe disease.

Related blog posts:

“Bowel Sounds” Pediatric GI Podcast: Dr. Martin and Dr. Vartabedian

It’s been nearly two years since the start of the NASPGHAN Bowel Sounds Podcast.

They are really good. While I am more of a visual learner, I like listening to the hosts banter at the beginning and then their capable interviews. The Podcasts have chosen terrific guests. You can read about and listen to all of the episodes at the NASPGAN website (link below), or listen on the go on Apple Podcasts, Spotify, Google Podcasts, or wherever else you listen to podcasts.

Here’s the NASPGHAN link: Bowel Sounds: The Pediatric GI Podcast

The two most recent podcasts (Dr. Martin and Dr. Vartabedian) exemplify the wide range of information available.

Dr. Martin Martin reviews the topic of congenital diarrheas and enteropathies (CODEs). Some key points:

  • History: Timing and Severity. Onset in the first week of life is suggestive of a congenital diarrhea (CODE). In those with later onset (eg. >4 weeks), need to consider infections, post-infectious diarrhea, and allergic disorders
  • Workup if suspicious of CODE -detailed in UpToDate (Dr. Martin is one of the authors). Many kids need serum studies, stool studies, imaging (AXR, UGI/SBFT) and EGD/Flex sig. In UpToDate, search either “congenital diarrhea” or “approach to chronic diarrhea in neonates and young infants (<6 months)” (36 pages)
  • Treatment: Most kids need a short (~24 hr) trial of NPO when there is adequate IV access to determine if diarrhea is malabsorption (goes away with fasting) and if diarrhea persists which is suggestive of an electrolyte transport-related diarrhea (aka. secretory diarrhea)
  • Dr. Martin advises use of bolus feeds when feeding trials are introduced in this population to get to an answer quicker. Usually with significant diarrhea, it is reasonable to start with a carbohydrate-free formula (eg. RCF formula). If there is not diarrhea with RCF, this suggests a carbohydrate malabsorption whereas ongoing diarrhea is suggestive of a more generalized malabsorption
  • Genetic testing should be performed earlier in the evaluation of those with a high suspicion of a CODE (eg. 1st week of life onset, severity, polyhydramnios, consanguinity) if the infectious workup is negative

Links:

  1. Advances in Evaluation of Chronic Diarrhea in Infants (nih.gov)
  2. PediCODE
  3. www.uptodate.com – Title: Approach to chronic diarrhea in neonates and young infants (<6 months)
  4. https://www.preventiongenetics.com/

Related blog posts:

Dr. Vartabedian, in his episode, discusses the importance of “owning your online identity as a physician, something “Dr. V” has written and spoken about extensively, including on his blog at 33charts.com” (from NASPGHAN website). He explains that everyone has a presence online and physicians can influence the content. At the very least, most physicians should make sure that their institutional profile looks good and that they take advantage of placing a profile on LinkedIn.

Other key points:

  • Dr. V’s book is available on 33charts (see link below)
  • Physicians can do a “vanity” search on Google and see what is posted about them
  • Dr. V recommends a book called “Keep Going” by Austin Kleon. “Whether you’re burned out, starting out, starting over, or wildly successful, Keep Going will help you stay on the path to more creative work.” (from Austin Kleon website)
  • Dr. V discusses a range issues which include negative physician reviews, online Trolls, and patient privacy

Links:

  1. The Public Physician | A Guide to Life in a Connected World
  2. 33charts.com (also be sure to sign up for the 33mail newsletter while you are there)

Related blog posts:

Colorectal Cancer in Patients Up to Age to 25 Years

In a nationwide retrospective cohort from The Netherlands (pop. ~17 million), a recent study (RM de Voer et al. Clin Gastroenterol Hepatol 2021; 19: 1642-1651. Full Text: Clinical, Pathology, Genetic, and Molecular Features of Colorectal Tumors in Adolescents and Adults 25 Years or Younger) characterizes the clinical and genetic features of colorectal cancer (CRC) in individuals <26 years of age (aka AYA group) from 2000-2017.

Key findings:

  • There were 139 patients in the AYA group identified: 9 (ages 10-15), 26 (ages 16-20), and 104 (ages 21-25)
  • Overall, the AYA group represents 0.1% of all CRC cases. However, AYA cases were much more likely to be at an advanced stage at diagnosis (66% at stage 3 or 4 compared with 46% of adults with CRC in The Netherlands).
  • Negative predictors for outcomes included age <16 yrs, signet ring cell carcinoma histology, and advanced stage at diagnosis.
  • Genetic tumor risk syndromes were identified in 39% and IBD was noted in 8.4% of the AYA group. The genetic risk is underestimated as the authors did not test for all CRC-predisposing genes. Lynch syndrome was the most common genetic disorder (identified in 22 patients) followed by familial adenomatous polyposis (identified in 5 patients)

Related blog posts: