Sarah Massey, APN, on Diagnosing and Monitoring Patients With IBD

Sarah Massey, APN, recaps her presentation at the AIBD APP Institute during the AIBD Annual Meeting on the essentials of diagnosing and monitoring ulcerative colitis and Crohn's disease.

Sarah Massey, MSN, APRN, is a board-certified nurse practitioner specializing in the care of patients with inflammatory bowel disease at the University of Chicago in Chicago, Illinois.

TRANSCRIPT:

Okay. Hi, good morning. My name is Sarah Massey. I am a nurse practitioner at the University of Chicago, and I'm here at the AIBD APP Institute. And this morning we talked a lot about diagnostics and monitoring in the IBD patient.

So just as a quick overview, we know IBD is an inflammatory condition associated with overactivation and loss of regulation of the body's immune system. We know that it affects more than just the bowel, most commonly the joints and skin. And we also reviewed a little bit of the difference between Crohn's and colitis where Crohn's has a patchy inflammatory pattern. It can occur anywhere from mouth to anus and has a transmural or full thickness inflammation. Therefore, structuring and penetrating complications are associated with Crohn's, whereas ulcerative colitis is limited to the large intestine or the colon and has a continuous pattern starting in the rectum continuing onward.

We also talked a lot about the diagnosis of inflammatory bowel disease and the considerations in the differential diagnoses. So we want to make sure we're ruling out infection, considering ischemic colitis, drug-induced enterocolitis with chronic NSAID use, medication-induced colitis with checkpoint inhibitor use malignancy, and of course functional causes.

And then we also talked about how to clarify the diagnosis, and that is done through a focal endoscopy with intubation up into the terminal ileum. We're making sure that we have biopsies of both the normal and abnormal mucosa. We're also relying on our expert pathologists to make sure that they're really having an understanding of what's going on under the microscope. We also want to be sure that we're having cross-sectional imaging of our patients with Crohn's disease and again, with CT or MR enterography.

And then we also talked a lot about monitoring strategies and how we do that. Monitoring strategies really have to be tailored to that patient and the phase of management. So monitoring during that pretreatment or induction of therapy maintenance. And then the recapture phase may look a little bit different. It's really important when we get our patients started on therapy. So have a clear set of benchmark biomarkers at the time of active disease. And more specifically, a lot of times we'll use a CRP, which is that nonspecific inflammatory marker. It's important to note that about 20% of patients don't mount a response to CRP. So it's really important to see if that is a good tool for us to monitor as we get them started on therapy and if they're one of those patients that don't mount a response. Similarly with stool calprotectin, we do know that it's much more specific in a patient with colonic disease rather than that small bowel Crohn's patient. An intestinal ultrasound can be used and can be used for both the Crohn's and colitis patient if available at your center.

We also went on to talk a little bit about that monitoring stage during the induction of therapy. So we should have a clear conversation with our patients about when our therapy should start working and when they should start feeling better, as well as when we should see that normalization of labs, stool testing and then scope. It's really important for us to enact a treat to target approach. So treat to target is a systematic approach to adjusting our therapies to achieve disease control and ultimately improve quality of life. Even though quality of life, of course, is our main goal, it's really important that we're acknowledging that these clear delineated targets are being met. And if they're not, we're readjusting our therapies, optimizing therapies, changing mechanisms, of course, considering surgery at certain points. It's also important to talk about that maintenance strategy, the monitoring strategy during maintenance phase.

And that's really, really important because we know controlled disease doesn't progress, whereas uncontrolled disease can progress. So we want to make sure that our patients are adhering to their therapies, they're actually taking their therapy. And we also know that relapse can happen probably most commonly within that first year, but not insignificant later. So we need to make sure that we're reassessing our patients constantly. And then to just briefly talk about that monitoring strategy during the recapture phase or for de-escalating our patients; again, de-escalation is not standard of care. Most of our patients are staying on therapies that are working, but we should consider that steroid withdrawal is a form of deintensification. And similarly, that patient that has been on a 5-ASA that has now advanced to a biologic and doing well on that biologic, when we move off of that 5-ASA, we may not think that it's doing much for their disease, but we should still do so systematically.

And finally, we really need to consider our patient and the prognostic factors of patients with Crohn's and colitis and who's at risk for surgery or complications. And our cadence monitoring really will reflect that patient. So that patient that is in stable remission, that hasn't had a low burden disease over time, may have a little bit of a different monitoring strategy than that high-risk patient that is now in stable remission. But it's taken really a lot to get them there. So altogether, it's really important for us to enact a proactive disease monitoring approach. It allows us to intervene early, optimize our therapies, and ultimately prevent clinical consequences.