Inflammatory bowel disease

Five things physicians and patients should question


May 31, 2017

1

Don’t use steroids (e.g., prednisone) for maintenance therapy in inflammatory bowel disease (IBD).

While systemic corticosteroids (e.g., prednisone) are effective in inducing symptomatic remission in IBD, they are ineffective as maintenance therapy and are associated with both short- and long-term serious adverse effects. Consequently, if the initial steroid taper is unsuccessful or more than two courses of steroids are required within a year, health providers should consider adding a steroid-sparing agent that has proven efficacy and safety as maintenance therapy in IBD patients.

2

Don’t use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD).

While opioids may be used to manage abdominal pain in select acute settings in IBD patients, their prolonged use may mask the symptoms of active IBD or its complications (e.g., bowel perforation or megacolon). Chronic opioid use has been proven ineffective for non-malignancy associated chronic pain and is associated with excess mortality. Moreover, because of their potential risk for dependence, their long-term use for managing IBD-related abdominal pain should be avoided especially in the context of the opioid crisis in North America.

3

Don’t unnecessarily prolong the course of intravenous corticosteroids in patients with acute severe ulcerative colitis (UC) in the absence of clinical response.

Non-response to intravenous corticosteroids for acute severe UC can be predicted after the first 72 hours of treatment. However, about a third of non-responders receive systemic steroid monotherapy beyond 7 days. This prolonged use of ineffective systemic steroids may unnecessarily lengthen hospitalization days and increase risk of postoperative complications in those who eventually require colectomy.

4

Don’t initiate or escalate long-term medical therapies for the treatment of inflammatory bowel disease (IBD) based only on symptoms.

Clinical symptoms often prompt initiation or escalation of medical treatments for inflammatory bowel disease (IBD). However, functional bowel disorders (e.g. irritable bowel syndrome) coexist in 20% of IBD patients and can mimic symptoms of the latter. Clinical symptoms, in fact, do not correlate well with IBD disease activity. Consequently, relying on only clinical symptoms without confirming active disease may commit patients to long-term treatments that have potentially significant adverse effects and resource implications.

5

Don’t use abdominal computed tomography (CT) scan to assess inflammatory bowel disease (IBD) in the acute setting unless there is suspicion of a complication (obstruction, perforation, abscess) or a non-IBD etiology for abdominal symptoms.

Abdominal CT scanning is effective for the time-sensitive diagnosis of IBD complications such as obstruction, perforation, or non-IBD related causes of abdominal pain when these are suspected. The effective ionizing radiation dose from a single conventional abdominal CT scan (10-20mSv) is within acceptable safety limits (<50mSv). However, minimizing inappropriate utilization of CT is a priority because repeated exposure to ionizing radiation over a lifetime, particularly among younger IBD patients, may potentially increase the risk of malignancy. In the acute setting (e.g., emergency department), abdominal CT scan should only be used when there is suspicion of a complication of IBD and should not be used for the assessment of disease activity.


How the list was created

The recommendation list was developed by the Canadian IBD Network for Research and Growth in Quality Improvement (CINERGI) in collaboration with Crohn’s and Colitis Canada (CCC) and the Canadian Association of Gastroenterology (CAG). The CINERGI group comprises 14 gastroenterologists specialized in the care of inflammatory bowel disease representing 12 academic centres across Canada. A preliminary survey was sent to the CINERGI working group to solicit candidate recommendations. The top 10 recommendations were selected by the working group members through an online voting platform. During a face-to-face consensus meeting in Toronto on November 4, 2016 that included CINERGI working group members, 2 radiologists, representatives from CCC and CAG, and 2 patient representatives, a modified Delphi process was used to select the top 5 recommendations. This list was submitted to the CAG Quality Affairs Committee, the Executive Board, and the CAG general membership for feedback and approval.


Sources

1

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2

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3

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4

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5

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