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.
Bressler B, et al. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology. 2015 May;148(5):1035-1058.e3. PMID: 25747596.
Gomollón F, et al. 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016: Part 1: Diagnosis and Medical Management. J Crohns Colitis. 2017 Jan;11(1):3-25. PMID: 27660341.
Harbord M, et al. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. J Crohns Colitis. 2017, 1–24.
Terdiman JP, et al. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn’s disease. Gastroenterology. 2013 Dec;145(6):1459-63. PMID: 24267474.Share on Facebook Share on Twitter
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.
Targownik LE, et al. The prevalence and predictors of opioid use in inflammatory bowel disease: a population-based analysis. Am J Gastroenterol. 2014 Oct;109(10):1613-20. PMID: 25178702.
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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.
Bitton A, et al. Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements. Am J Gastroenterol. 2012 Feb;107(2):179-94. PMID: 22108451.
Kaplan GG, et al. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Gastroenterology. 2008 Mar;134(3):680-7. PMID: 18242604.
Nguyen GC, et al. Quality of Care and Outcomes Among Hospitalized Inflammatory Bowel Disease Patients: A Multicenter Retrospective Study. Inflamm Bowel Dis. 2017 May;23(5):695-701. PMID: 28426451.
Randall J, et al. Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications. Br J Surg. 2010 Mar;97(3):404-9. PMID: 20101648.Share on Facebook Share on Twitter
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.
Abdalla MI, et al. Prevalence and Impact of Inflammatory Bowel Disease-Irritable Bowel Syndrome on Patient-reported Outcomes in CCFA Partners. Inflamm Bowel Dis. 2017 Feb;23(2):325-331. PMID: 28092305.
Colombel JF, et al. Management Strategies to Improve Outcomes of Patients with Inflammatory Bowel Diseases. Gastroenterology. 2017 Feb;152(2):351-361.e5. PMID: 27720840.Share on Facebook Share on Twitter
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.
Kim DH. ACR Appropriateness Criteria Crohn Disease. J Am Coll Radiol. 2015 Oct;12(10):1048-57.e4. PMID: 26435118.
Smith-Bindman R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009 Dec 14;169(22):2078-86. PMID: 20008690.Share on Facebook Share on Twitter