Quality care = Work Satisfaction for Physicians

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From Atul Gawande’s twitter feed:

RAND study:

“Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” Full article: http://bit.ly/19vVAnK 

1) Best predictor of MD work satisfaction: how we rate system’s care quality.  Physicians who felt that they were working in an environment with high quality care had higher work satisfaction.

2) Bad EHRs are killing us.  (Related blog entry: Aptly titled “The Cost of Technology” | gutsandgrowth)

 

A C difficile two-fer

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Two recent review articles on Clostridium difficile are quite useful:

  • Mezoff EA, Cohen MB. J Pediatr 2013; 163: 627-30.
  • Dupont HL. Clin Gastroenterol Hepatol 2013; 11: 1216-23.

The first publication reviews acid suppression and the risk of C difficile infection (CDI).  It starts off with  a terrific piece of advice from Sir William Osler: “One of the first duties of the physician is to educate the masses not to take medicine.”  The authors note that pH above 4 has been shown to increase bacterial survival, including  C perfringe spores in a mouse model.  In addition, the article notes that there have been concerns as early as 1982 that acid suppression could be a risk factor for CDI.  Several recent studies were summarized, including the following:

  • A recent meta-analysis (Kwok CS et al. Am J Gastroenterol 2012; 107: 1011-9) with 42 studies (N= 313,000 patients) “found an association between PPI use and risk of CDI (OR1.74, 05%CI 1.47-2.85).”
  • A review of the literature (Deshpande A et. Clin Gastroenterol Hepatol 2012; 10: 225-33) between 1990-2010 found an overall increase in CDI risk with PPIs to be OR 2.15 (95% CI 1.81-2.55). No prospective studies were identified.
  • In pediatrics, a study (Turco et al. Alimentary Pharmacol Therapeut 2010; 31: 754-9) with 910 children admitted for abdominal pain and diarrhea identified 68 with CDI.  Compared with control patients, use of PPIs was significantly higher in CDI patients (OR 4.52, 95% CI 1.4-14.4).

The FDA has stated that PPIs may be associated with an increased risk of CDI.  In addition, the use of antibiotics “appear to act synergistically with PPIs.”  Thus, the authors recommend stopping PPIs in those who do not need them.  Periodic ‘holidays’ or dosing step-downs may help assess continued need for PPIs.

The second publication succinctly reviews the diagnosis and management of CDI.  The various diagnostic methods are compared in Table 1.  Therapeutic options for 1st time infection are reviewed in Table 2.  For adults with mild-to-moderate infections, metronidazole (500 mg TID for 10 days) is preferred.  Vancomycin or Fidaxomicin are recommended for more severe infections.

Table 3 lists treatment options for recurrent CDI.  Repeat course of any of the 1st round treatments can be considered depending on patient’s illness severity.  In addition, other potential treatments included the following:

  • vancomycin tapered dose (week 1: 125 mg 4 times/day, week 2: 125 mg 2 times/day, week 3: 125 mg once/day, week 4: 125 mg every other day, week 5 & 6: 125 mg every third day)
  • rifaximin (550 mg BID x 20 days)
  • high-dose vancomycin (250-500 mg 4 times/day for 10 days) followed by S boulardii (2 capsules BID for 28 d)
  • fecal microbiota transfer (FMT) –“although family member stool donors have been used, the current movement is toward volunteer donor pools.”  [I do not think ‘current movement’ was intended as a pun by the authors.]  Volunteer donors could lower the screening costs.
  • intravenous immunoglobulin (small clinical trials have failed to show efficacy)
  • monoclonal antibodies to toxins A/B

Related blog posts:

Nutrition Module

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More notes from this year’s postgraduate course:

Clinical issues in parenteral nutrition, Praveen S. Goday, MBBS, CNSC (page 105)

  • Fish‐oil vs minimizing soybean oil‐based lipid emulsions
  • Catheter‐related bloodstream infections (CRBSI): Ethanol locks “Humans like ethanol and bacterial don’t.”  Meta‐analysis:  In comparison with heparin locks, ETOH locks (various regimens) reduced the following: a) CRBSI‐rate per 1000 catheter days by 7.67 events (81% ↓)  b) catheter replacements by 5.07 (72% ↓), c) 108‐150 catheter days of ETOH lock exposure were necessary to prevent 1 CRBSI, d) Adverse events – rare and included thrombotic events.  Reference: Oliveira et al. Pediatrics 2012;129:318–329

Parenteral Drug Shortages: All PN products except dextrose and water have been in short supply at some point since spring 2010

Imported components from Europe (higher cost)

• Peditrace™ – zinc, copper, manganese, selenium, fluoride, and iodine

• Addamel N™ – zinc, copper, manganese, selenium, fluoride, and iodine, molybdenum, iron, and chromium

Summary / Take‐home points

  • Reduction in soybean oil emulsion or provision of fish oil emulsion results in improvement in cholestasis
  • Ethanol lock therapy decreases CRBSI in children on home PN
  • Significant PN shortages have affected our ability to care for our PN patients; thus need vigilance and good communication between physician, dietitian and pharmacist

Severe Obesity in Your Clinic: The disconnect between the epidemic and the intervention Sarah E. Barlow, MD, MPH (page 125)

What to do for obesity?

  • Behavior modification
  • Pharmacotherapy (and behavior modification)
  1. Orlistat (Xenical, Alli) -Enteric lipase inhibitor, FDA approved starting at age 12 years (OTC $200 per month)
  2. Approved for adults Lorcaserin (Belviq): 5-HT2C agonist
  3. Approved for adults: phentermine and topirimate (Qsymia)
  • Surgery (and behavior modification)
  • Meal replacement (and behavior modification)

Orlistat trial for adolescent obesity:

  • 54 week double-blind RCT
  • 539 subjects: 12 to 16 years of age, BMI 36 ±  4 kg/m2
  • BMI change kg/m2 (mean):  – .55  vs. + 0.31 for control
  • Fecal urgency (%) 20.7 (11.0 in controls)
  • Flatulence (%) 9.1 (4.4 in controls)
  • Fecal incontinence (%) 8.8 (0.6 in controls)
  • Reference: Chanoine et al. JAMA 2005;293:2873

Orlistat meta-analysis among adults :

  • -2.87 kg [95CI -3.21, -2.53] = placebo-subtracted change at 1 year
  • Reference  Rucker D. BMJ 2007;225:1194

Multiple potential medications are being studied

Selection criteria for adolescent bariatric surgery

  • Tanner stage IV or V
  • BMI ≥ 35 kg/m2 with severe
  • Comorbidity or BMI ≥ 40 kg/m2 with comorbidity
  • “Have failed” 6 month of organized attempts at weight loss
  • Committed to pre and post medical and psychological care
  • Supportive family
  • Able to give informed assent
  • Frequent barriers: Distance from center, Insurance, Age, Reluctance
  • Reference: Pratt Obesity 2009;17:901

Complications from Surgery

  • For all procedures: nutritional deficiencies, especially iron, vitamins B12, D, and thiamine
  • For gastric bypass: postprandial hypoglycemia in adults
  • For lap band: need for re-operation for slippage or erosion in adults and small adolescent study.
  • Also pouch dilatation
  • For sleeve gastrectomy: leak or bleeding along suture site

Summary

  1. 4% of children 6 to 19 are severely obese
  2. Severe obesity leads to high levels of cardiovascular disease risk factors, NAFLD, OSA, and pre-diabetes
  3. Behavior modification has modest efficacy, is a partner in all other intensive interventions, but is not readily available behavior modification is underutilized because it is time-intensive and resource-intensive.  It it is necessary even though it is not sufficient.
  4. Orlistat is the only medication currently available for adolescents.

 5 2 1 0

  • 5 servings of fruits and vegetables a day
  • 2 hours or less of screen time
  • 1 hour (60 minutes) or more of physical activity
  • 0 sugar-sweetened beverages

Postgraduate Course Syllabus (posted with permission): PG Syllabus

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

Why U.S. Consumers Pay More For Medications

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The NY Times has highlighted the high cost of medical care in the U.S. in a series of articles.  While only affecting about 10% of the total U.S. health cost, the wide variation in the cost of medicines between the U.S. and other countries leaves the U.S. consumer feeling ‘ripped-off.’

Here’s the link:  bit.ly/17p8kKR (from Jay Bookman) and here’s an excerpt:

Pulmicort, a steroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.

“The one that really blew my mind was the nasal spray,” said Robin Levi, Hannah and Abby’s mother, referring to her $80 co-payment for Rhinocort Aqua, a prescription drug that was selling for more than $250 a month in Oakland pharmacies last year but costs under $7 in Europe, where it is available over the counter…

Unlike other countries, where the government directly or indirectly sets an allowed national wholesale price for each drug, the United States leaves prices to market competition among pharmaceutical companies, including generic drug makers. But competition is often a mirage in today’s health care arena — a surprising number of lifesaving drugs are made by only one manufacturer — and businesses often successfully blunt market forces….

On the same topic, in Forbes: forbes.com/sites/peterubel/2013/10/15/-expensive-new-drugs/ …

In the U.S., the FDA must deem a drug safe and effective before allowing it on the market.  But at that point, there are no economic barriers to the use of those medications.  By contrast, drugs in the United Kingdom must go through economic analyses by a unit known as NICE—United Kingdom’s National Institute for Health and Clinical Excellence.  Being safe and effective is not enough to pass muster with NICE.  The drug must also be cost effective. …

Should we demand proof of cost effectiveness before allowing drugs on the market?  Or before agreeing to pay for them in Medicare and Medicaid?  Doing so would undoubtedly reduce healthcare expenses.  With medical spending threatening our fiscal future, it makes no sense that Medicare is prevented by law from considering the cost of care when making coverage decisions.  You heard that right—forbidden by law!

Related Blog Post:

Should Physicians Dispense Drug Coupons? | gutsandgrowth

Update on Hepatitis B & C -Postgraduate Course

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Update on Hepatitis B –Jean Pappas Molleston

Hepatitis B: Who to Treat:

  • Immune active Hepatitis B with active disease: HBeAg+ (> 6 months), HBV DNA > 20,000 IU/ml, ALT > 1.5 x normal or > 60 IU/L, &  moderate/severe inflammation/fibrosis
  • Reactivated Hepatitis B with active disease: HBeAg‐ (> 12 months), HBV DNA > 2000 IU/ml, ALT > 1.5 x normal or > 60 IU/L

Hepatitis B: Who to Not Treat:

  • Immunotolerant Hepatitis B: HBeAg+, HBV DNA > 20,000 IU/ml, Normal ALT
  • Inactive carrier: HBe Ag, HBV DNA < 2000

What to Use to Treat Children with Hepatitis B and When:

  • Only children with active disease should be treated
  • Many would suggest IFN as a first line drug, especially for younger children
  • Nucleoside analogues can now be considered in older children: Tenofovir is licensed for over age 12,  Entecavir is licensed for over age 16

What’s Exciting?

  • NCT01519960 Peg‐IFN monotherapy for children with chronic active hepatitis B
  • NCT01368497 Peg‐IFN and Entecavir for treatment of Hepatitis B in immunotolerant children
  • New drugs
  • New ways to predict who will have worse disease and who will respond
  • Direct Acting Antivirals

Treating HCV: 2013 and Beyond… Regino P. González-Peralta, M.D.

Standard of Care HCV Therapy: Children

  1. IFN/PEG-IFN-α-2a (PEG-2a):  ‘‘Branched’’ 40-kDa PEG moiety, Dose: 104 μg/m2 SQ once weekly, Available: prefilled syringes or as vials
  2. PEG-IFN-α-2b (PEG-2b): ‘‘Linear’’ 12-kDa PEG, Dose: 60 μg/m2 SQ once weekly, Available: Measured vials/ready-use pens

Other pointers:

  • Discussed IL-28 B Polymorphism –No pediatric data yet
  • Close monitoring for those who are treated
  • PEG-RBV is standard of care for children though with suboptimal efficacy and significant toxicity
  • Warp-speed evolution of HCV therapies
  • All ORAL’ regimen on horizon
  • Yearly evaluation: CBC, liver tests, HCV RNA and PT/INR (cirrhosis)

HCV Rx in Children: to treat or not:

IN FAVOR…

  • Avoid disease progression
  • Remove social stigma
  • Decrease HCV burden
  • Children ‘better’ candidates

…AGAINST

  • Benign disease
  • Efficacy
  • Toxicity
  • Direct Acting Antivirals (in the pipeline)

Full slides available on postgraduate Course Syllabus (posted with permission): PG Syllabus

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

One More Day Syndrome & Necrotizing Enterocolitis

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In many situations, the advice is to wait one more day and then decide/act; however, sometimes one more day winds up being a week, a month, or longer.  A recent editorial indicates that there is enough evidence now for probiotic usage in neonates to prevent necrotizing enterocolitis (NEC).  The authors state that to continue “with the standard of care, in which no new products are provided…is ethically unacceptable” (JAMA Pediatrics 2013; 167: 885-6).  Thanks to Ben Gold for this reference.

Key arguments:

  • A 2011 Cochrane review identified 16 eligible trials with 2842 premature infants (<2500 g, <37 weeks).  Probiotics reduced the incidence of NEC with a relative risk of 0.35 and mortality with a relative risk of 0.40.  Despite the typically cautious recommendations from Cochrane reviews, the authors state “updated review of available evidence supports a change in practice.”
  • While the American Academy of Pediatrics in 2010 noted there is some evidence to support probiotic usage and called for more studies, there are no studies currently being conducted in the U.S.
  • The authors note that the “FDA Center for Biologic Evaluation and Research is committed to policies that effectively prohibit probiotic efficacy trials.” Under current policies, the authors state these “studies will not be conducted in a US setting for the next 20 to 30 years.”
  • Other countries , like Australia, allow use of probiotic with parental consent.
  • The authors propose that probiotic efficacy be studied in a comparative effectiveness design.

Bottomline: Current regulations have stymied the use of probiotic trials for NEC.  What will it take for regulatory agencies to relent and allow this promising research?

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

Civet Cat Poop Coffee

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From KT Park’s twitter feed: npr.org/blogs/thesalt/2013/09/02/218232266/is-your-pricey-cup-of-cat-poop-coffee-fake-there-s-a-test-for-that …

Dr. Balistreri briefly referred to civet cat poop coffee in his clinical year in review of studies.  This year’s focus was on the microbiome.  The lecture pulled together a large number of divergent sources to show how the microbiome can affect everything, including inflammatory bowel disease, colic and obesity.  The reference to Civet Cat poop coffee indicates that ingesting stool may not be as disgusting as it sounds.

TPN Drug Shortages -A Useful Reference

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A recent article in Today’s Dietician offers advice on drug shortages with TPN.

The following is a link (from a Kipp Ellsworth retweet) and an excerpt: http://t.co/CBKti0mNep

Lipids. Two US manufacturers produce three lipid concentrations  (10%, 20%, and 30%) of IV fat emulsions. The 30% concentration can be used only  in total nutrient admixtures. ICU patients receiving propofol can forgo IV fat  emulsions, since propofol is in a lipid-based emulsion that provides 1.1  kcal/mL, just like the 10% IV fat emulsion.

Since essential fatty acid deficiency doesn’t develop until  after two weeks of lipid-free PN, IV fat emulsions can be safely withheld for  the first two weeks if lipids are in short supply.1 After two weeks of  lipid-free PN, the minimum dose of IV fat emulsions, which is 100 g/week, can  be provided to prevent essential fatty acid deficiency.

IV fat emulsions should be discontinued in patients  tolerating EN and who don’t have malabsorption concerns.

IV Multiple Vitamins               When there’s a shortage of IV multiple vitamins, dietitians  should evaluate all patients for their ability to absorb enteral multiple  vitamin supplements in capsule, tablet, liquid, or chewable forms. For patients  who can’t absorb enteral vitamin supplements, the IV multiple vitamin dose  should be decreased from 10 mL to 5 mL/day to conserve supplies. If IV multiple  vitamins remain in short supply despite conservation efforts, the standard dose  of 10 mL should be given three times per week.2

If supplies have been exhausted, PN must be supplemented  intravenously with individual parenteral vitamins according to the following  ASPEN recommendations: thiamin: 6 mg; folate: 0.6 mg; ascorbic acid: 200 mg;  pyridoxine: 6 mg; and vitamin K: 0.5 to 1 mg/day or 5 to 10 mg/week.2 In  addition, cyanocobalamin (vitamin B12) must be given intramuscularly at least  once per month.2

Trace Elements               Combination trace elements and individual trace element  products offer alternatives to PN products in short supply.

Combination Multiple Trace Element Products               Dietitians have a choice of two different multiple trace  element combination products: MTE4 and MTE5. MTE4 products contain zinc,  copper, chromium, and manganese and come in a standard 3 mL dose or a 1 mL  concentrated dose. MTE5 products contain the same four trace elements with the  addition of selenium in either the standard 3 mL dose or the 1 mL concentrated  dose.

If there’s a shortage of the concentrated products, RDs can  use the standard 3 mL dose of MTE4 and MTE5. When MTE4 products aren’t  available, RDs can substitute the MTE5 products. If MTE5 products aren’t  available, RDs should substitute MTE4 products and add 60 mcg of selenium  individually to achieve the equivalent composition of MTE5.

…If no MTE products are available, individual trace elements  should be added to PN solutions.

Individual Trace Elements               Individual trace elements are used when combination trace  element products are unavailable…

There’s no need to supplement manganese when there are  shortages of multiple trace element products. Whole blood manganese levels  frequently are elevated in long-term PN patients, and manganese contamination  often occurs in other PN products. No alternative IV forms of chromium are  available but, like manganese, there may be some chromium despite the fact it  isn’t intentionally added because of its contamination potential in other PN  products. RDs can evaluate a patient’s ability to absorb chromium as part of  multivitamin and mineral supplementation through the enteral route and monitor  for signs of deficiencies.

Other than the selenium content of MTE5 products, selenium  is available as a single IV trace element product. When MTE5 products and individual  IV selenium products aren’t available, RDs can consider using oral selenium  supplementation.

Copper is available as a single PN trace element in two  forms: IV copper chloride or IV cupric sulfate. If all supplies of IV copper  have been exhausted, a patient should be evaluated for oral copper supplements.

Zinc is available in either IV zinc sulfate or IV zinc  chloride. It’s important to note that if zinc is given enterally in high doses,  RDs should monitor for a copper deficiency, as zinc and copper both compete for  absorption with the same carrier protein when EN is used….

— Mandy L. Corrigan,  MPH, RD, LD, CNSC, is a nutrition support dietitian with Coram Specialty  Infusion Pharmacy.

 Professional  Resources • American Society of Health-System Pharmacists Drug  Shortages Resource Center: www.ashp.org/menu/DrugShortages

• American Society for Parenteral and Enteral Nutrition Drug  Shortages Update: www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update

• FDA Current Drug Shortages Index: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

• FDA Fact Sheet: Drug Products in Shortage in the United  States: www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/ SignificantAmendmentstotheFDCAct/FDASIA/ucm313121.htm

• FDA Frequently Asked Questions About Drug Shortages: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm

• Fresenius Kabi Adult Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM355392.pdf

• Fresenius Kabi Pediatric Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354265.pdf

• Fresenius Kabi Phosphate Injection Availability (product  information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354277.pdf

• National Medication Errors Reporting Program (patients and  clinicians): www.ismp.org/orderforms/reporterrortoISMP.asp

 

For More Information               The following references can serve as viable resources for  dietitians to learn more about parenteral nutrition drug shortages and their  impact on patient safety and patient care:

• Buchman AL, Howard LJ, Guenter P, Nishikawa RA, Compher  CW, Tappenden KA. Micronutrients in parenteral nutrition: too little or too  much? The past, present, and recommendations for the future. Gastroenterology.  2009;137(5 Suppl):S1-S6.

• Corrigan ML, Kirby DF. Impact of a national shortage of  sterile ethanol on a home parenteral nutrition practice: a case series. JPEN  J Parenter Enteral Nutr. 2012;36(4):476-480.

• Holcombe B. Parenteral nutrition product shortages: impact  on safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):44S-47S.

Related Blog Posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

PSC 2013 Review

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A recent review of PSC was published (Gastroenterology 2013; 145: 521-36).  This review is a little more detailed than a previous review noted in this blog less than 6 months ago (Staying current with PSC | gutsandgrowth).

A couple of useful comments from the review:

  • “An increased serum level of alkaline phosphatase is the most common biochemical abnormality detected in patients with PSC.  In some cases, it is the only biochemical alteration observed, such as in patients with intrahepatic involvement.”
  • “Typically, a liver biopsy is not required to diagnose PSC unless small duct PSC is suspected or if there are concerns that a patient also has AIH.”  Cholangiography is the best way to identify PSC.
  • “Patients diagnosed with PSC should undergo colonoscopy… to determine if they have IBD, even when there are no symptoms.”
  • Autoimmune hepatitis-PSC overlap is thought to occur in ≤6% of cases.  AIH-PSC should be suspected if there are biochemical features of AIH (positive serology, increased transaminases), histology suggestive of AIH, or in AIH patients that become refractory to treatment.
  • No controlled trials have identified effective medical treatments.  Studied medications have included corticosteroids, etanercept, tacrolimus, cyclosporine, azathioprine, methotrexate, infliximab, and ursodeoxycholic acid.  The latter may increase disease progression, particularly at higher doses.

Also noted:

Hepatology 2013; 58: 1392-1400. “Primary Sclerosing Cholangitis, Autoimmune Hepatitis, and Overlap in Utah Children: Epidemiology and Natural History”

In this study the authors identified 607 cases of IBD, 29 cases of PSC, 12 cases of ASC (overlap), and 44 cases of AIH.  “Cholangiocarcinoma developed in 2 of the 29 PSC patients (6.9%).  PSC occurred in 9.9% of patients with ulcerative colitis (UC) and 0.6% of patients with Crohn’s disease.”

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

Top Lecture: Enteral Nutrition for Crohn’s Disease

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In my opinion, the best lecture from this year’s postgraduate course was from Dr. Baldassano.  Enteral nutrition in Crohn disease: Where should this be in our treatment algorithm?  Robert N. Baldassano, MD (page 115)

Dr. Baldassono has personal experience with improving with enteral therapy after failing methotrexate/remicade.  His conclusion:

Enteral Nutritional Therapy: Where should this be in our treatment algorithm?

  • Should be offered to all newly diagnosed Crohn’s patients who can tolerate Nutritional Therapy
  • Special groups (especially a good idea): Malnourished patients, Younger patients, Growth failure, History of Cancer, Family history of Lymphoma, Consider when failing other therapies

This conclusion is supported by his presentation.

Should we be immunosuppressing our Patients?  Hypothesis: IBD arises from inappropriate handling of intestinal bacteria

Elements of Modern Lifestyle Lead to Changes in Gut Microbiota

  1. Improved sanitation
  2. Less crowded living conditions
  3. Decline in parasites
  4. Vaccinations
  5. Increased antibiotic use
  6. Caesarean section
  7. Refrigeration
  8. Food processing
  9. Diet changes
  10. Improved sanitation

Diet is associated with new onset IBD

  • High dietary intakes of total fats, PUFAs, omega‐6 and meat were associated with an increased risk of CD and UC
  • High fiber and fruit intakes were associated with decreased CD risk
  • High vegetable intake was associated with decreased UC risk.  Reference: Hou JK et al. American Journal of Gastro 2011; 106:563-73
  • The Bacteroides enterotype highly associated with animal protein and saturated fats which suggests meat consumption as in a Western diet
  • The Prevotella enterotype, high values for carbohydrates and simple sugars, indicating association with a carbohydrate-based diet, more typical of agrarian societies.  References: Wu G, et al. Science. 2011 Oct 7;334(6052):105‐8

Partial or Complete Enteral Nutrition?

  • 50% vs 100% of total caloric needs for induction with elemental formula (PCDAI < 10 at 6 weeks)
  • 50% of total caloric needs 15% remission
  • 100% of total caloric needs 42% remission
  • Labs improved only in the 100% group
  • Weight gain similar in the 2 groups. References: Akobeng et al Clin Nutr 2007; Ludvigsson et al Acta Paediatr 2004;Johnson et al Gut 2006;Critch et al. JPGN: 2012 

Pediatric Longitudinal Study of Semi‐Elemental Diet and Stool Microbiome (PLEASE)

Prospective cohort study of children with Crohn disease from Philadelphia (used Peptamen), Toronto (used Modulen) and Halifax (used Osmolite); (n=90)

  • Enteral therapy with defined formula diet (n=38) vs. anti‐TNFα therapy (n=52)
  • Similar drop in PCDAI and calprotectin in TNF group and diet group. 

Other points:

  1. Insurance generally will cover nasogastric feeds
  2. Disease location –not clear that this matters with Crohn’s disease
  3. The reason EN works may be not what you are giving the patient but what the patient is not getting
  4. Bacterial populations in pediatric IBD subjects on semi‐elemental diet (16S rDNA sequencing) develop a rapid change in gut bacterial populations upon initiating diet.
  5. Partial (50%) nutrition, as noted above, helped maintain remission compared to normal diet.

Nutrition Therapy: “European” Protocol

• Induction:  Exclusive enteral nutrition with an elemental, semielemental,or polymeric formula

• Duration: 4 – 12 weeks

• Maintenance Therapy: (either)

– Nutritional therapy: Repeat 4 week cycle of exclusive enteral nutrition every 3– 4 months

OR

– Medical therapy: 6‐MP/AZA/MTX after induction with nutritional therapy

CHOP EN Experience: What if >80% of calories is from Enteral Nutrition?

  • Methods: Semi‐elemental formula, 80%‐90% of patient’s caloric needs from formula, Nocturnal NG feeds (outpatient teaching program), Normal diet as tolerated during the day
  • Duration:  7 days per week for 8‐12 weeks (induction), 5 days per week (maintenance) Reference: Gupta et al. Inflamm Bowel Dis. 2013:1374-8.
  • Induction of remission: 65% (at 8 weeks)
  • Response: 87% (at 8 weeks)
  • Significant improvement in weight and linear growth
  • Protocol is well tolerated:  no serious adverse events

Postgraduate Course Syllabus (posted with permission): PG Syllabus

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.