Drs. Boland, DiBaise, Konijeti, Matro, Sklow, and Worsey answer questions from course participants.
I can start off with some questions. One of the first questions that probably pulled through I would ask glory to respond to this. What is the panel's view on the rule of antibiotic prophylaxis when patients are being discharged on cortical steroids. There's some guidance from I. D. S. A. But when applied to IBD patterns abated but I think there may be some specific aspects related to uh numerous cysts profile axis or other things. Yeah I think that that's a great question and I would say that specifically as it relates to Pneumocystis this the rates of Pneumocystis in IBD patients whether on biologics or multiple forms of immunosuppressive therapy is very low. Um That said in practice I do find that when patients are on the hospitalist service and I'm discharging them after say rescue therapy with I. V. Steroids on high dose steroids there often and inflicts map or any other biologic. They're often also sent home on Bactrim prophylaxis when they're on the G. I. Service. We have another their discussion about whether or not we really need this. Um I think you know the overall risk of being on antibiotic prophylaxis is I mean you know you don't have G. Six pd deficiency or other issues is fairly low. So the benefits there especially if you think this patient is going to be on high dose steroids for a long time while you're trying to assess whether given therapy is working for them or whether they're not say like do a biologics or multi drug therapy may be beneficial. Um But it's not really clear that all patients needed, particularly if you anticipate they're going to be able to taper off stories quickly. Um In other situations I think the one thing I would like to mention a c. Diff oftentimes we're co treating their IBD flair and their c diff infection. And I do you find that that's a situation where when they're discharged from the hospital, I do find it helpful to have a longer course of seed of treatment uh such as a taper uh in order to really give their IBD time to get under control while getting the steroids down. I'd be interested to see what other panelists have to say. I agree with dr khanna Jetty. And the other thing to remember is that generally patients who are receiving the call center and inhibitors like cyclospora and have a higher risk of uh P. J. P. And so those are patients that um should be sent home generally on on prophylaxis. So the next question Dr Metro and I'm glad that we have two surgeons applies to them also. So first dvt profile axes in the setting of acute severe ulcerative colitis. Both as an inpatient and outpatient and a follow up question to the surgeons acute severe ulcerative colitis surgery or Crohn's disease surgery. Liberty profile axis as impatient and subsequently continuing as outpatient. It's a good question. Um In the hospital they certainly should be getting pharmacologic DVt prophylaxis. So sub cue heparin or Lovenox at just the prophylactic doses Um You know the data looking at continuing some form of um prophylaxis after admission for acute severe you see or some IBD complication. Um You know I think is is mixed. Um It's not really something that's a standard practice at least where we are. Um Though in patients who are high risk you might consider it okay certainly patients who have a prior history for for reason one reason or another. Um But pharmacologic prophylaxis in the hospital for sure I can address the extended profile axis. My practice probably since 2014 when I wrote an article on high rates of post discharge V. T. E. And IBD patients uh that patients should get 28 days of extended prophylaxis um following hospitalization. So that's been my practice. It's a practice of many surgeons at the Cleveland clinic. It's not yet a standard or guideline in the United States like cancer. But we're hoping to move that direction. Be interested to see what dr words he thinks in the era of enhanced recovery where our patients get minimally invasive surgery and up walking the same day of surgery. And thereafter I think it's becoming a less of a risk in that respect. I haven't set my patients home on long term post up D. V. T. Prophylaxis but uh I'd be uh interested in that paper and perhaps I should be doing that. Uh But I think now we emulate our patients on the first day it's less of an issue, but certainly still in the hospital very necessary. Yeah. Uh question for democracy base. Um there are people with genuine short hours people who want to be short powers. So they may not have a surgical resection to that extent, but they experience on the same symptoms. We believe they have enough of small tower in place or at least have the colon in place. How do you distinguish those two? And there's every short bowel patients have to have diarrhea and high output. Or how do you manage? Some of those patients who have the colon intact, maybe having one or two power movements but still experience nutritional depletion. Thanks sid. So, uh I think uh the diagnosis of short Powell is actually not so straightforward. I in my in the single slide I showed it's it's kind of gave more of a functional definition rather than putting a specific number on the the amount of bowel left and particularly in a Crohn's population where they may have some active disease. So they may have a sufficient, even though they've had multiple receptions, they may not meet sort of what you would think would be uh the amount of bowel removed to meet any sort of definition of short bowel. However, you know, with the active disease is sort of put them over the edge and they've kind of developed a functional short bowel and I think one of the things that I see quite often are patients who are have had usually just some terminally ill resection? They have a high cost system or they have a high output. Usually they still have their colon and continuity and they're kind of referred to me for management of short bowel syndrome, where they clearly don't have short bowel syndrome. Um why is that? Well, there are different reasons, particularly for terminally ill re sections and maybe a portion of the colon, bile acid, diarrhoea, fat malabsorption that's unrelated to short bowel syndrome. So, um what about those patients had mentioned, who, you know, who had intestinal resection but don't have diarrhea? Well, they probably don't have short bowel syndrome. If they don't have diarrhea, diarrhea is going to be the major symptom that that we need to manage in patients with short bowel syndrome. Mhm. And if they don't have it, they probably don't have short bowel syndrome. Okay, now that is very helpful because we come across these patients and it's a struggle. They don't feel well. Overall, after the search reason, the question is, like you said, the short vowel diagnosis gets a little more challenging in that situation. Um, question for dr Bolen, we always have these patients come up and say, how do I time? My covid vaccine with regard to my biologic agents, can I take it any time? Or do you have a preferred answer or you're just encouraging them to go ahead and take it any. Which time? Yeah I think that you know there's not a whole lot of data on this. Although there's not a whole lot of rationale to expect a whole lot of interactions. Even most of these biologics are around in our body you know hopefully at trough as well as um you know right after you get the doses. I think the key thing is ideally separating them out by a few days just in case there are um reactions, responses. I think um you know we just be able to decipher what is what and mostly for everyone's peace of mind you know a lot of people feel lousy after the vaccine and so at least you can figure out what is what um You know I think also when the vaccine initially came out we kind of said get it as soon as you can. But I think now you can you know there's more ability to time things just not the same day as your infusion or spread them out by a few days. Um And then I think steroids are the big thing that I would try to get down if you could. Perfect question for dr Barcia and doctors flow both of you may have independent thoughts about the timing of biologics prior to a surgery whether it be an I. P. A. Or whether the occasions related surgery with the primary anastomosis. Do you care. Do you care about the kind of biological or does it go into your surgical decision making they receive that biological week prior to surgery? I can stop there. My preference has always been. I'd like to do Miss one or 2 doses. I guess the the literature now is somewhat equivocal on that. But if you were up to me alone I would have the Miss one and perhaps two doses of a biologic. So uh safer crones. Usually it's kind of arbitrary but three weeks at least three weeks before um for all sort of colitis, it's a lot of these patients are more urgent in the hospital. Um It hasn't been an issue as recently because there's a lot of them are getting three staged. But I'm doing a college reception for Crohn's and they've been on an anti TNF. I would say about three weeks and then post up. I tell them to hold maybe one dose and restart the regiment if they're going to restart it. Three or four weeks post up. Okay. Uh huh. Question for all the panelists. Because I don't want to put dr Poland on the spot. The anecdotal reports data suggesting some people after a Covid vaccine flare up or get a new diagnosis of IBD. Any thoughts experience anecdotes. I can I can start I mean, I think that, you know, I've seen a few cases like this. I think it's important to take a step back and look at the data in totality that I don't think there's a whole lot of evidence is a significant risk and the there are known risk of getting covid. So I you know I think it's important to kind of keep the big picture in mind. I think I would just add that you know the data she showed right was that patients on biologics actually seemed to have fewer symptoms in general after vaccination compared to non IBD patients. Um And the other is just that in general after vaccination the rate of symptoms is up to 50% even in a non IBD population. And so even if a patient does have nausea, vomiting diarrhea it doesn't always mean that it's a flare of their IBD. But certainly could be something that mimics the IBD symptoms or maybe you know has the potential to exhaust your favorite. Okay uh Next question. Uh Last question for documentary all patients are failing outpatient corticosteroids gets admitted to the hospital with that you see here you see should we go straight to inflict snap. Is there any point of doing I. V. Steroids or if they, yes if they have not if they've been on oral steroids as an outpatient I think the important thing is bringing them in for a flex sig ruling on CMB because the risk Christianity is higher in these um oral steroid non responders. Um And then while you're preparing for inflicts a map getting the uh TB testing and hepatitis B. And that sort of thing. Certainly trying I. V. Steroids is reasonable. So you should be preparing for for uh something like conflicts and every one of the other options that we discussed. Yeah I'll have one final question because the ramos at the top of time somebody with inter abdominal ab says fish killer or somebody with obstructive symptoms get re admitted to the hospital. When do you say it's time for surgery? When do you say? I think I can manage medically um gory and dr marci. Yeah. Uh So you're saying they've already had this admission? You thought you had it under control sent them home and now they're bouncing back with the same thing. I see. So I think you just have to ask yourself whether medical therapies you know pre cutaneous drainage antibiotics whether these are working. And most often you know when they're bouncing back they've typically been hopefully started on some form of IBD therapy. Um But it's really yeah reassessing and taking it one day at a time and really trying to determine if the approach we're taking is the right one. I do think though you know again if they have official of they have a tight structure leading to an abscess. You know if they have some of these priests pneumatic dilation or high risk features. These patients are often just best served by surgery first and then we can really come up with a plan for HIV treatment or prevention afterwards. Doctor we're seeing any thoughts. I agree. And I think our pounds very enlightened, sugary is not a failure and sometimes an operation to get rid of the disease that's not responding and and to reset um, is a good idea. So I think that when things aren't working, uh operation, uh, even early is not a bad idea.
