Treatment of Extra-intestinal
Manifestations of IBD: Case studies
Alan C. Moss MD, FEBG, FACG
Associate Professor of Medicine
Director of Translational Research
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
Trend in Hematologic Indices
Hematocrit (40-50%)
Iron Profile
What would you do next?
A.
B.
C.
D.
E.
Increase oral iron dose
Blood transfusion
Iron infusion
Erythropoietin
All of the above
Causes of Anemia in IBD
Iron
Deficiency
20% of Out-patients
60% of Hospitalized patients
Chronic
Disease
Bone marrow suppression
Drug-induced hemolysis
Vitamin B12 / folic acid deficiency
Gisbert J, Am J Gastroenterol. 2008 May;103(5):1299-307.
Determining Iron Deficiency in IBD
Gasche C, Inflamm Bowel Dis 2007;13:1545-1553
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
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
Erythropoietin for Anemia in IBD
Schreiber s N Engl J Med. 1996 Mar 7;334(10):619-23
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
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)
Sigmoidoscopy
What would you suggest next?
A.
B.
C.
D.
Low Molecular Weight Heparin
Unfractionated Heparin
Vena caval filter
Other
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
VTE Prophylaxis is Under-Utilized in IBD
Table 3. Nursing administration of prophylaxis
‘All’
‘None’
Number of hospital days with
VTE prophylaxis ordered
Percentage of doses administered
<25%
25-49%
50-79%
>80%
100%
N = 113
60 (53%)
7 (6%)
12 (11%)
14 (12%)
20 (18%)
Actual administration of
ordered doses by nurses
Pleet J et al , DDW 2013, S434
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