DAY 3: What IBD Patients Want to Know

Case 1: A 28-year-old woman with a 3-year history of ulcerative pancolitis is experiencing symptoms and says she heard online that probiotics can treat inflammation. She asks if she can just buy some probiotics from her health food store and if she would be able to stop taking her biologic.

Dr. Jacob M. Skeans, from The Ohio State University in Columbus, OH, reviewed what is known about the gut microbiome and how it affects inflammation, and suggested ways to respond to this patient. Key messages might include a discussion of dysbiosis and how it disrupts health, and the goal of re-establishing microbiome diversity and balance to improve resistance to disease. In IBD, an immune response is mounted against the pattern of gut bacteria that was set up at birth, leading to inflammation. While fecal microbiota transfer to try and re-establish a healthy gut microbiome showed promise as a therapy for UC, evidence of its effects in CD is evolving, and it is no longer available in the US. Approved donor-derived microbiome therapies have been shown to work well in patients with recurrent Clostridium difficile infection with and without IBD. Novel therapies for the treatment of IBD are being explored, but phase 2 trials showed no benefit. Clinicians could acknowledge the promise of probiotics in IBD, but there is not enough evidence that they should be given to patients. Instead, this patient could be counseled to make dietary changes that can have beneficial effects on the gut microbiome within 1-2 weeks.

Case 2:  A 34-year-old woman with 9-year history of ileocolonic CD who initially responded to corticosteroids transitioned to infliximab and then risankizumab. She says she feels 80% better and asks if she can skip the next colonoscopy. She explains that she cannot take off work, hates the prep, and always gets sick after anesthesia.

Dr. Michael T. Dolinger from the NYU Grossman School of Medicine, Morristown, NJ, suggested taking a patient-centered approach, asking the patient what is important to them, as perfection can be the enemy of the good. But he would also explain that it is critical to assess the ileum to understand if the disease is progressing, even if symptoms are stable. For this patient, Dr. Dolinger made the case for offering a non-invasive surveillance modality like ultrasound or MRI. Ultrasound provides a look at the entire colon in real-time, with no sedation or contrast. Patients can see thickening and swelling of the bowel wall that indicates inflammation and thinning in response to treatment. It is important to have a benchmark map of the ileum for each patient, so that treatment goals can be set and treatments can be matched to that target. Ultrasound can facilitate shared decision-making and active conversations about treatment planning. Colonoscopy timing can be based on the ultrasound results; if a patient is responding to treatment, it might be acceptable to wait a little longer for colonoscopy. This patient might be counseled to try dietary changes or supplements to try to get her closer to feeling 100% better. Dr. Dolinger suggested being creative about meeting patients where they are. He also mentioned a new 1-year fellows certification pathway offered through the Intestinal Ultrasound Group of the United States and Canada (IUSCAN) that includes an e-learning pathway, in-person courses at DDW, virtual and in-person mentors, and a final in-person hands-on competency assessment.

Case 3: A 42-year-old woman presents for follow up of ileocolonic Crohn’s disease (CD), which was diagnosed 12 years ago. She underwent an ileocecectomy 7 years ago for fibrostenotic disease and has remained in clinical and endoscopic remission on ustekinumab for the past 3 years. She is obese with hypertension, prediabetes, and fatty liver disease. She has gained 40 pounds while in remission and explains that her primary care doctor wants to start her on a GLP-1, but she is worried it will cause abdominal problems that sound like CD symptoms. She asks if it will make CD worse and whether it is safe to take with ustekinumab.

Dr. Oriana M. Damas of the University of Miami in Miami, FL, described that the GLP-1 receptor is located in many organs, where it can reduce inflammation. This has led to an ever expanding list of potential indications beyond weight loss and diabetes. She noted that up to 40% of adults with IBD are also obese. Evidence for GLP-1 RA in IBD mostly comes from retrospective cohorts and case studies, but each show that they work for weight loss in patients with IBD and do not appear to make CD worse. There is no data on anti-inflammatory effects of GLP-1 RAs in IBD. Dr. Damas raised two safety considerations in IBD: first, delayed gastric emptying may increase the risk of obstruction in stricturing ileal disease, and second, there may be an interaction with immunomodulators that use weight-based dosing, for example, the risk of hepatotoxicity is higher with azathioprine and semaglutide. Dr. Damas would tell this patient that GLP-1 RAs work in people with IBD the same way they work in those without IBD, and there is no evidence that it will worsen CD. She would also emphasize that GLP-1 RA side effects can mimic a flare, and that it is important to monitor both muscle mass and hydration, not just the number on the scale. 

Case 4: A 29-year-old man with 2-year history of ileocolonic CD was hospitalized 6 months ago for a disease flare (SES-CD 12). He completed prednisone and started on infliximab and azathioprine. During his visit, he says he’s been reading that CD is really caused by processed food, and the nutrition influencers he’s following have recommended 8 different diets to try. He asks if he can stop his biologic therapy if he changes his diet.

Dr. Damas reviewed what is known about the effects of various diets in IBD, including the Mediterranean diet, low-fat/high-fiber diet, UC exclusion diet, 4-SURE diet, CDED with partial enteral nutrition, fasting mimicking diet, and low emulsifier diet. Only the Mediterranean diet has been tested against usual diet in a randomized controlled trial in UC. No dietary therapy induces remission as a monotherapy in moderate-to-severe UC and the risk is that an advanced therapy will be delayed in order to trial a diet. Optimizing nutrition is important. Benefits have been noted with the fasting mimicking diet in UC but enteral nutrition shows no benefit. In CD, benefits have been seen with the CDED diet, partial enteral nutrition added to anti-TNF therapy, and the fasting mimicking diet. For this patient, Dr. Damas would ask what he is already eating or has already eliminated from his diet, and then try to default to a Mediterranean pattern based on AGA best practice recommendations. She recommends screening for malnutrition and nutrient deficiencies and never letting diet delay initiation of an effective therapy. She recommends working with a dietician if one is available, or finding virtual resources. It is also important to gauge patient interest in dietary changes, as some patents want to eat what they want. In the end, there are diets with supporting evidence that can be implemented if a patient is ready to try them.