Controversies and questions related to the ongoing management of stable, controlled IBD

Over the years there have been attempts at standardizing care for the patient with inflammatory bowel disease (IBD). I was the director of AGA’s initiative to establish quality metrics for the care of patients with IBD in 2011. Subramanian and Triadafilopoulos published a review in 2016,1 and Berry and Melmed published an excellent review this year.2 In this perspective, I have chosen to apply the quality measures into a succinct and practical guide to the management of IBD in patients whose disease is in clinical remission.

I begin with the typical patient with asymptomatic, treated IBD. When I take over the care of a new patient with IBD who is in remission, I establish the expectations for care going forward. Patients in remission still require monitoring. The specific parameters that should be monitored can vary depending on the disease and the medications that have been used to maintain that remission. The following is what I would consider a reasonable approach based on my 30 years in the IBD field and discussions with several of my colleagues across the country who specialize in IBD. Given that IBD referral practices may not have unlimited access to the patient, treatment can be coordinated with the patient’s primary care physician. It should be noted that clinical remission is not necessarily histologic remission, so a careful history is necessary to delineate subtle signs and symptoms of disease progression that warrant further investigation.

I recommend office visits every six to 12 months, with a complete blood count (CBC) and a comprehensive metabolic panel (CMP) at a minimum every six to 12 months in all patients regardless of their medication regimen. Likely all patients should be vaccinated for hepatitis B virus (HBV) at entry to the practice if they are not already immunized. This in effect would eliminate the concern for reactivation of HBV upon immunosuppression if and when it would be needed. The practical challenge is having the patient back for subsequent immunization on time.

I advocate influenza and pneumococcal vaccinations as well as the new recombinant herpes zoster vaccine, especially in patients receiving tofacitinib. With regard to patients taking tofacitinib, their lipid levels should also be followed, typically on a quarterly basis.

I recommend annual vitamin B12 and 25-OH vitamin D levels on all patients with Crohn disease as well as in patients with a history of ileostomy/Ileoanal anastomosis. The exception to this would be a patient already taking parenteral vitamin B12 whose measurement would only note treatment compliance or lack thereof.

If patient is taking a thiopurine, then I recommend a CBC and CMP or liver panel every three months, and I will only prescribe a three- month supply of medication at a time; I will not renew the prescription unless those laboratory values have been reviewed. There is precedence that all patients taking a thiopurine should have thiopurine methyltransferase (TPMT) genotype testing performed to avoid toxicity in the 10 percent of the population with aberrant TPMT. An additional genetic defect in TPMT metabolism has been identified in patients from Central America and parts of Asia. Currently, I am not checking for this mutation.

Patients taking sulfasalazine likely require a CBC, CMP or liver panel every three months based on published recommendations. In patients taking mesalamine, some experts also advocate urinalysis on a yearly basis.

In patients who are immunosuppressed, once their HBV status is known to not be immune and no immunization has occurred, I recommend annual hepatitis B surface antigen (HBsAg) testing. Some of my colleagues have suggested that unless their patients practice high-risk behaviors, they do not check HBsAg on an annual basis. Because the ramifications of immunosuppressing a patient with active HBV infection are significant, I test all who are not known to be immune. In addition, I order an interferon-gamma release assay for tuberculosis. A purified protein derivative skin text could be performed; however, follow-up with the patient can be challenging when that visit must be in 48 hours to have the results reviewed and documented.

I believe the above regimen is a starting point for the care of patients with IBD whose disease is in remission. To date, no published consensus statement exists on this topic. I believe our professional societies should generate scientifically based recommendations, because third-party payors are beginning to require mandatory office visits to approve payment for biologics and future payor-based parameters may not be scientifically sound.

Key takeaways

  • Patients with IBD whose disease is in remission should be monitored on a regular basis.
  • The specific disease, medical regimen and patient anatomy will determine the appropriate monitoring for each individual patient.

Dr. Rood has no conflicts to disclose.

References
1. Subramanian, C.R., Triadafi G. Care of the infl bowel disease patients in remission. Gastroenterol Rep. 2016;4:261-271.
2. Berry, S.K., Melmed, G.Y. Quality indicators in infl bowel disease. Intest Res. 2018;16:43-47.

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