Suspected IBD Outpatient Flare
|
Objective: Optimal management of IBD flare. |
|
Patient population: Adult patients (>18 years) with known diagnosis of IBD. |
Highlight BoxThe completed assessment will be used to triage patient symptoms to determine the degree of urgency. Good clinical judgement, assessment skills and knowledge of IBD will be utilized in consultation with the physician or nurse practitioner to determine further treatment or assessment required. |
Introduction
An IBD flare is the reappearance of disease symptoms. This CCP is intended to support clinicians in outpatient settings with their decision-making process when faced with concerns for a flare. Please see the steps mentioned below.
Management
1. Gather information using the Inflammatory Bowel Disease Patient Phone Consultation form.
2. Utilize the information collected to complete the Harvey Bradshaw Index (HBI) or Partial Mayo (pMayo) with the patient; if the patient has IBDU (IBD unclassified), an HBI will be used.
3. Communicate the completed assessment to the responsible physician/nurse practitioner (NP) within the following timelines:
| Timeline | Patient Assessment Guidelines | Mode of Communication | ||
|---|---|---|---|---|
|
Urgent/Emergent |
|
|
||
|
Semi-urgent |
|
|
4. Under the direction of the physician/NP, or standard operating procedure process laboratory/diagnostic imaging investigations based on the assessment:
a. IBD Flare Lab Requisition (CBC, FER, NA, K, CL, ALB, ALP, ALT, CRP, AST).
b. Stool C. diff and culture and sensitivity (if diarrhea present) Microbiology Requisition: Stool C.Diff, Culture & Sensitivity. (PACE QPI 1)
c. Stool Fecal Calprotectin (if available.
d. Ova and Parasite should be added if the patient has recently travelled, was camping, or was exposed to well water.
e. X-ray of abdomen with 3 views if the patient is experiencing bloating, abdominal pain, nausea, vomiting.
f. If the introduction of a biologic is considered, see IBD patients starting biologic-induction regime for pre-biologic work-up
5. Deliver requisitions to the patient by one of the following methods:
a. fax requisition to the patient’s closest laboratory/radiology centre
b. send the requisition to the patient via email, standard mail or fax
c. give the requisitions to the patient if the patient is present in clinic
6. Patient is to contact the clinic once testing is complete.
7. Review the results with the physician/NP to determine further investigations, follow-up, or treatment change.
Caution: ‘’Although x-rays have a moderate sensitivity for the detection of high-grade small bowel obstruction, they are less useful in differentiating small from a large bowel obstruction and differentiating partial obstruction from ileus. Follow-up abdominal CT is generally required’’.
Physician Guided:
8. Consider the following imaging:
a. CT enterography/ MR enterography U/S: when patient present with abdominal pain to right upper quadrant, history of abscess/stricture. Surgery referral if needing EUA, seton placement, drainage of abscess, resection
b. Abdominal ultrasound or Point-of-care Intestinal Ultrasound (where available)
c. MRI pelvis: if new fistula or pain
d. Endoscopy depending on history to document disease extent and severity
e. Urgent surgery referral for assessment
9. If the patient:
a. Has moderate to severe active disease, and infection has been ruled out
b. Previously had good response to Corticosteroids (40 mg -60 mg per day for >14 days) with no or minor side effects (PACE QPI 3)
c. Had not required two or more courses of systemic steroids in the last year (PACE QPI 7) Consider Corticosteroids tapering course and refer to: Initiation and Maintenance of Corticosteroids
d. If the patient has left-sided disease add rectal therapy of 5 ASA supps or foam or 5 ASA or steroid enemas.
10. If the patient is on biologics, consider antibody serum levels, dose escalation or rescue dose.
a. Consider therapeutic drug monitoring if the patient is on biologic therapy.
11. If the patient is on Azathioprine (stable dose for 1 month or following a change in dose). (6TG & 6MMP Therapeutic Levels)
12. Decide on the timeline for a follow-up clinic/virtual visit or telephone to initiate care.
REFERENCES:
Feagan BG, Rutgeerts P, Sands BE, Hanauer S, Colombel JF, Sandborn WJ, et al. Vedolizumab
as induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2013; 369(8): 699–710. https://doi.org/10.1056/nejmoa1215734
Guidi L, Pugliese D, Panici Tonucci T, Bertani L, Costa F, Privitera G, et al. Early vedolizumab
trough levels predict treatment persistence over the first year in inflammatory bowel disease.
United European Gastroenterol J. 2019; 7(9): 1189–97. https://doi.org/10.1177/2050640619873784
Maglinte D. et al. Radiology of small bowel obstruction: contemporary approach and controversies. Abdominal Imaging. 2003; 30(2):160-78. https://doi.org/10.1007/s00261-004-0211-6
Sandborn WJ, Feagan BG, Rutgeerts P, Hanauer S, Colombel JF, Sands BE, et al. Vedolizumab
as induction and maintenance therapy for Crohn’s disease. N Engl J Med. 2013; 369(8): 711–21. https://doi.org/10.1056/nejmoa1215739
Shmais M, Regueiro M, Hashash JG. Proactive versus Reactive Therapeutic Drug Monitoring: Why, When, and How? Inflammatory Intestinal Disease. 2021 Sep 6;7(1):50-58. https://doi.org/10.1159/000518755
Verstockt B, Dreesen E, Noman M, Outtier A, Van den Berghe N, Aerden I, et al. Ustekinumab
Exposure-outcome analysis in Crohn’s disease only in part explains limited endoscopic remission rates. J Crohns Colitis. 2019; 13(7): 864–72. https://doi.org/10.1093/ecco-jcc/jjz008