Treating the Outpatient with Severe IBD: Case Discussions

William Tremaine, MD Corey A. Siegel, MD

Tremaine Case 1

• 36 year old man, college custodian • Onset 6 months ago of diarrhea, some stools mixed with blood, urgency, abdominal cramps.

• Evaluated 5 months ago: • Negative stool studies for infection • Flexible sigmoidoscopy: moderately active colitis as far as examined • Biopsies: Chronic colitis, no granulomas

Tremaine Case 1

continued • Started: Prednisone 40 mg/d, tapered over 6wk Mesalamine 1.2 g BID • Improved, but worsened 1 week off prednisone • Restarted Prednisone, tapered over 6 wk • Started Azathioprine 2.4 mg/kg/d • Improved, but worsened 1 week off prednisone

Tremaine Case 1

continued • Check stools for infection again…

negative

• Colonoscopy with biopsies…

left sided UC, biopsies showed chronic colitis, stains negative for CMV

• MR enterography?...

not done

Tremaine Case 1

continued • Infliximab added • Continued symptoms after 4 weeks • Restarted Prednisone 40 mg/day, improved

Tremaine Case 1

continued • Stopped mesalamine • Tapered and discontinued prednisone • No symptoms on Azathioprine and Infliximab

Exacerbation of UC with Mesalamine

• 2 case reports • Both got worse on mesalamine • Both improved on prednisone • One of the patients • In remission off meds • • • Flex sig showed quiet disease Challenged with two 4gm mesalamine enemas Repeat flex sig after 24 hours • Marked worsening • Biopsies showed eosinophils and neutrophils Sturgeon JB et al.

Gastroenterology

1995; 108: 1889-93

Tremaine Case 2

• 53 year old nephrologist • Ulcerative proctitis for 35 years • Extends 12 cm above the dentate • Intermittent symptoms • Poorly controlled with: • Mesalamine oral and rectal • • Steroids oral and rectal Azathioprine 2.5 mg/kg for 4 month trial

Tremaine Case 2

continued • Stool studies: no infection • Colonoscopy • • Moderate proctitis Normal above the rectum to the cecum • Biopsies • Chronic colitis • No granulomas, inclusions, dysplasia • Current Symptoms • Fecal urgency, stools or mucus >10 day, including 2 3 nocturnal stools

Tremaine Case 2

continued What to do?

1.

2.

Proctocolectomy with J pouch Anti TNFα therapy 3.

Methotrexate 4.

Tacrolimus 5.

Diverting sigmoid colostomy

Tremaine Case 2

continued • Tacrolimus suppositories • 1 mg compounded in local pharmacy • Tacrolimus blood level 12 hours post suppository • 3.4 ng/ml • Suppositories gradually decreased to once each 2-3 nights, as needed

Tacrolimus Suppositories for Ulcerative Proctitis

μg/L • Netherlands, multi-center 6 Tacrolimus Blood level • Suppository composition • • Tacrolimus capsules adeps solidus 5 4 3 • Whole blood trough levels 2 • 10/12 pt (83%) improved 1 0 2hr 4hr 6hr 24hr Van Dieren JM et al.

Inflamm Bowel Dis

2009; 15:193-198

Tremaine Case 3

• 40 year old hair stylist • Previous smoker, stopped 7 years ago • Ulcerative colitis, hepatic flexure distally, for 5 years • Treated with mesalamine 1.2 g BID • • Remission for 3 years Then recurrent symptoms • Controlled with prednisone • On Prednisone > 6 months in the past year • Hates prednisone, feels jittery

Tremaine Case 3

continued • Weight gain of 25 kg • Increased ALT, Alkaline Phos.

• • Ultrasound: steatosis Lost weight with dieting, liver tests normalized • One year ago, left eye pain and loss of vision • Diagnosis, optic neuritis, treated with i.v. steroids • resolved over 14 days, no subsequent neurologic symptoms

Tremaine Case 3

continued • Current symptoms • 4-6 stools daily, some with blood, urgency • Abdominal cramping pain 3-4 /10 severity • Stopped mesalamine for a 5 days, worsened, restarted • Declines further steroids • Stools negative for infection • Liver enzymes, TPMT normal • Azathioprine: fever after 3 days to 102 °F, resolved after 2 days off azathioprine

Tremaine Case 3

continued 4.

5.

6.

Treatment options?

1.

2.

Proctocolectomy with J pouch Anti TNFα therapy 3.

6-mercaptopurine Methotrexate Cyclosporine A Oral mesalamine plus mesalamine enemas

Methotrexate in UC: Veterans Study

• National VA database • 2001-2011 • 91 pt with UC met criteria • Methotrexate • • Prednisone > 15 mo follow-up • Methotrexate • • Oral: 68 pt I.M., S.Q. 23 pt 14mg/wk 25mg/wk • Prednisone Initial average Dose • • Oral MTX group: 12 mg/d I.M., S.Q MTX group: 25 mg/d

%

50 45 40 35 30 25 20 15 10 5 0

12 Month Follow-up

Off Prednisone Khan N et al.

Inflam Bowel Dis

2013; 19: 1379-83 MTX Oral MTX I.M., S.Q.

Tremaine Case 3

continued • Treated with • MTX 25 mg S.Q. weekly • Folic acid 2 mg p.o. daily • Continued oral mesalamine 1.2 g BID • Symptoms largely resolved after 2 months

Tremaine Case 4

• 34 year old attorney • UC with pan-colonic involvement for 12 years • Continued symptoms despite: • mesalamine • • prednisone azathioprine, nausea • • Mercaptopurine Anti TNFα biologics, 2 agents • Currently: 2-3 stools a day with blood mixed Urgency, cramps

Tremaine Case 4

continued • Stool studies negative for infection • Colonoscopy • Biopsies: moderate activity • Treatment options • Proctocolectomy with J pouch • • • Calcineurin inhibitor Methotrexate Anti-diarrheals, anti spasmodics

• • • • •

Oral Tacrolimus Maintenance Rx for Refractory UC

50

6 Month Outcome %

45 London, retrospective 40 25 pt with UC Remission 35 Failed steroids • 23 failed thiopurines • 5 failed anti TNFα 30 25 20 Adverse Effects Tacrolimus 0.1 mg/kg/day • 12 hour dosing 15 10 Trough levels 5-10ng/ml 5 0

Landy J et al J Crohn’s & Colitis 2013; 7: e516-21

Tremaine Case 4

continued • Treatment • Tacrolimus 2 mg Q12 hours • Dose adjusted upwards to trough level 8-10 ng/ml • Prednisone 40 mg/day • Tapered and stopped after 4 weeks • • • • Methotrexate 25 mg S.Q. weekly Folic acid 2 mg /day TMP/SMZ DS twice weekly while on prednisone Calcium, Vitamin D • Tacrolimus and MTX continued for 6 mo, then Tacrolimus was stopped

Siegel Case 1

• 36 year old woman, attorney – NH public defender • Diagnosed with Crohn’s disease at age 15 • Colonic and perianal disease • Prior use of 6MP, infliximab (secondary non-responder), adalimumab (horrible psoriasis) • Colectomy with ileostomy and Hartmann’s pouch 2011 • Fine OFF all meds until 2013…

Siegel Case 1

continued • Presumed peristomal pyoderma

Siegel Case 1

continued • Ileoscopy showed 5cm of mildly active inflammation in most distal neo-terminal ileum (active chronic non specific enteritis), mild diversion colitis • Topical tacrolimus for pyoderma, budesonide for small bowel inflammation – no improvement in skin (worse)

Siegel Case 1

continued Treatment options and rate of success

Treatment

Steroid injection Topical antibiotics Systemic steroids Systemic antibiotics Systemic cyclosporine Infliximab Stoma closure

Receiving Rx

4 5 8 6 7 6 5

Rx Successful

1 1 1 1 2 2 5

% success

25% 20% 12% 17% 29% 33% 100% Poritz LS, et al. J Am Coll Surg 2008;206:311

Siegel Case 1

continued • No response to intralesional steroid injection, antibiotics, prednisone 40mg, oral antibiotics • Sulfa allergy prevented use of dapsone • Ustekinumab (anti-IL23) ?

• Responding very nicely after 1 st 2 doses of ustekinumab!

Guenova E, et al. Arch Dermatol 2011;147:1203. Am J Gastroenterol 2012; 107:794.

Siegel Case 2

• 26 year old woman, works part-time for a coffee roaster • Diagnosed with Crohn’s disease at age 15 • Perianal and colonic disease, s/p subtotal colectomy with ileosigmoid anastomosis at age 19 • 6MP with GREAT drug levels, but… • Recurrent colonic disease and NEW diffuse small bowel disease • Suicidal on prednisone (police intervention!) • Infusion reaction to to infliximab, short duration response to adalimumab, no response to certolizumab

Siegel Case 2

continued • Prochymal (mesenchymal stem cell) trial – no response • Natalizumab for 3 months, no benefit (and scared) • Next treatment options?

 Methotrexate   TPN Antibiotics and budesonide  Another clinical trial  Off label use of something

Siegel Case 2

continued • Start ustekinumab • 90mg SQ at week 0 and 2, then every 8 weeks Sandborn WJ, et al. N Engl J Med 2012;367:1519-28

Siegel Case 2

continued • D i d very well for 1 year, then symptoms returned, endoscopically active disease (small bowel and colon), losing weight • Next steps?

• After ruling out infection and immune deficiency syndrome, starting tofacitinib • Oral JAK inhibitor (UC and Crohn’s) • At 15mg, dose dependent increase in LDL • Treating with 10mg PO bid

28.1% 33.7% 38.8% 40.8%

Sandborn WJ, Ghosh S, Panes, J, et al. Gastroenterology 2011;140:S124

Siegel Case 3 •

20 year old woman, college student majoring in sociology

•

Diagnosed at age 16 with ileal and esophageal disease

•

Pancreatitis to 6MP, serious delayed hypersensitivity reaction to infliximab

•

Secondary loss of response to adalimumab

•

Certolizumab + methotrexate with good ileal response, but persistent esophageal disease

Siegel Case 3

continued

•

Management of esophageal Crohn’s    PPIs Topical agents Systemic agents

Siegel Case 4 •

22 year old gentleman, college student

•

3 year history of ulcerative colitis, transverse colon to rectum

•

Failing 5-ASAs and oral steroids

•

Brief response with 1 st persistent symptoms infliximab dose, but

20 year old male with UC: varying clearance of infliximab over the course of a flare

8 days after an infiximab dose, drug level = 1.8

Dose 1

5mg/kg

9/24/12 Dose 2

5mg/kg

10/10/12 Dose 3

5mg/kg

11/12/12 Dose 4

10mg/kg

12/26/12 Data courtesy of Dr. Randall Pellish, UMASS Medical Center Slide created by Kimberly Thompson, Dartmouth-Hitchcock Medical Center

16+ weeks!

Dose 5

5mg/kg

4/19/13