Common Mistakes in Managing Patients with Inflammatory Bowel Disease
Abstract
:1. Introduction
2. Diagnosis and Differential Diagnosis
2.1. When Admitting Previously Diagnosed UC Patients with Rectal Bleeding, It Is Not Necessary to Rule Out an Enteric Infection as It Is Evident that It Is a Flare-Up of Their IBD
2.2. C. difficile Infection Should Only Be Considered in IBD Patients Who Have Recently Received Antibiotics
2.3. Assume That All Cases of Proctitis Are Ulcerative Proctitis
2.4. The Endoscopic Lesions of UC Are Always Continuous
2.5. In Severe UC Flare-Ups, a Complete Colonoscopy Is Necessary to Precisely Define the Extent of the Disease and Choose the Most Appropriate Treatment
2.6. An Obstructive Picture in Patients with CD Is Always Due to Intestinal Stenosis as a Consequence of Their Underlying Disease
2.7. The Clinical Manifestations of Toxic Megacolon Are Very Characteristic, So Its Diagnosis Is Usually Straightforward
2.8. CMV Infection, Whenever Present, Always Plays a Causative Role in the Flare-Up of UC or in the Episode of Corticosteroid Refractoriness
3. Prevention
3.1. For Patients with CD Who Smoke, Repeatedly Emphasizing the Necessity of Quitting Smoking May Not Be So Crucial
3.2. Early Screening for Latent Tuberculosis Is Not Necessary; It Is Sufficient to Screen Only When the Patient Already Requires Immunosuppressive Treatment
3.3. Routinely Assessing the Need for Vaccination at the Time of Diagnosis Is Not Necessary in Patients with IBD
4. Nutrition and Diet
4.1. Self-Imposed Food Restrictions Help Prevent the Onset of IBD Flare-Ups and Aid in Controlling Their Activity
4.2. Patients Admitted for an IBD Flare Benefit from Complete Fasting, as It Reduces Disease Activity; The Administration Route for Nutritional Supplements Should Be Parenteral, as It Is More Effective and Better Tolerated Than Enteral Feeding
5. Aminosalicylates
5.1. Aminosalicylates Are Equally Effective for Treating CD and UC
5.2. The Combination of Oral and Topical Aminosalicylates Is Deemed Unnecessary, as Each Treatment Alone Demonstrates Similar Efficacy
5.3. The Total Dose of Aminosalicylates Should Be Split into at Least Two Daily Administrations, as a Single Daily Dose Is Less Effective
6. Corticosteroids
6.1. Corticosteroids Are Generally Used Appropriately (Only When Necessary)
6.2. Corticosteroids Are Effective in Patients Who Are Already Receiving Treatment with Immunomodulators or Biological Agents
6.3. It Is Recommended to Start with Low or Intermediate Doses of Corticosteroids, and Only Use Full Doses if No Response Is Observed
6.4. At Least 10 Days Must Pass before Considering a Patient with Severe UC Treated with Intravenous Corticosteroids as Corticosteroid-Refractory
6.5. Faced with a Patient with Severe UC Resistant to Corticosteroids Who Has a CMV Infection and Has Started Antiviral Treatment, It Is Necessary to Immediately and Completely Discontinue the Steroids
6.6. Since Bone Loss Does Not Begin to Occur until Several Months after the Start of Corticosteroid Treatment, It Is Not Necessary to Initially Administer Prophylactic Therapy for Osteopenia
7. Thiopurines
7.1. It Is Advisable to Split the Dose of Thiopurines into Several Intakes to Facilitate Gastric Tolerance
7.2. In Patients Who Develop Digestive Intolerance to Azathioprine, Thiopurine Drugs Should Be Permanently Discontinued
7.3. Thiopurines Should Always Be Stopped and Non-Thiopurine Therapy Used Instead if Liver Abnormalities Are Detected
7.4. Thiopurines Should Always Be Discontinued if Myelotoxicity Is Detected
7.5. Withdrawal of Thiopurines (When Administered as Monotherapy) Should Be Strongly Recommended in All Patients after Several Years in Remission
8. Anti-TNF Agents
8.1. Anti-TNFs Are Not Useful for Treating Stricturing CD, Which Will Always Require Endoscopic Dilation or Surgery
8.2. De-Escalation of Anti-TNF Treatment (Either Reducing the Dose or Increasing the Administration Interval) in IBD Is Generally Recommendable
9. Extraintestinal Manifestations
9.1. In Hospitalized UC Patients, Thromboprophylaxis Is Not Indicated, as They Are Usually Young (and Therefore at Low Risk) and Have Rectal Bleeding (Which Could Worsen with Anticoagulation)
9.2. Ocular Manifestations of IBD Are Never an Emergency, and Therefore, Patients Experiencing Them Should Be Referred to an Ophthalmologist for Deferred Outpatient Evaluation
10. Anemia
10.1. Anemia (i.e., Low Hemoglobin Levels), Not Iron Deficiency (i.e., Low Ferritin Levels), Is the Only Significant Laboratory Finding
10.2. The Impact of Anemia on the Quality of Life of Patients with IBD Is Quite Limited
10.3. Since Mild Anemia Is Common in Patients with IBD and Its Clinical Impact Is Only Evident When the Anemia Is Severe, Iron Therapy Is Rarely Necessary
10.4. When Administering Oral Iron Treatment, Higher-Than-Usual Doses Should Be Used Because Its Absorption Is Often Decreased in Patients with IBD
10.5. In Patients with IBD, Intravenous Iron Administration Should Be Reserved for Cases of Severe Anemia (e.g., Hemoglobin < 8 g/dL)
11. Elderly Patients
12. Pregnancy
12.1. During Pregnancy, Endoscopic Examinations Should Not Be Performed Even if They Are Clearly Indicated, Due to the Risk of Harming the Fetus
12.2. In Pregnant Women, Due to the Risk that Medications Pose to Fetuses, Efforts Should Be Made to Administer the Minimum Possible Treatment for IBD, Even if It Means that Some Intestinal Activity Persists
12.3. Biological Agents Are Not Safe during Pregnancy, and Therefore, They Should Be Discontinued before the Third Trimester
12.4. Breastfeeding Is Contraindicated While the Mother Is Undergoing Treatment with Biological Agents
12.5. In Children Exposed In Utero to Biologics, Non-Live Inactivated Vaccines Are Less Effective and Safe
12.6. In Children Exposed In Utero to Biologics, All Live-Attenuated Vaccines Are Safe
12.7. Administration of a Live-Attenuated Vaccine to a Breastfed Infant While the Mother Is Receiving Anti-TNF Agents Is Not Recommended Unless Infant Anti-TNF Serum Levels Are Undetectable
- (a)
- Multiple studies have consistently demonstrated that peak levels of infliximab in breast milk are minimal, typically less than 1% of maternal serum levels (see corresponding section above);
- (b)
- (c)
- The EMA’s recommendation was primarily based on a case report involving two mothers receiving infliximab while breastfeeding. One infant’s infliximab serum levels were undetectable, whereas the second infant’s levels were measured at 1.7 μg/L during maternal induction treatment, equivalent to approximately 2% of the maternal serum infliximab level at that time [328];
- (d)
- The largest study on biological treatment during breastfeeding involved 29 women treated with infliximab. This study confirmed very low levels of infliximab in breast milk and demonstrated that breastfed infants of mothers using biologics, including infliximab, had similar risks of infection and rates of milestone achievement compared to non-breastfed infants or infants not exposed to biologics [304];
- (e)
- In the most recent study evaluating the risk of serious adverse events associated with live-attenuated vaccines in children breastfed by mothers receiving biological therapies—the DUMBO registry [329]—a quarter of breastfeeding mothers were on biologics (mostly anti-TNF agents). Sixty-eight percent of these children breastfed for at least 6 months received the rotavirus vaccine, 97% received the first dose of the trivalent MMR (measles, mumps, rubella) vaccine if they were breastfed for at least 12 months, and 84% received the first dose of the varicella vaccine if they were breastfed for at least 15 months. No serious adverse events related to these live-attenuated vaccines were reported [330];
- (f)
- The recommendation against administering live-attenuated vaccines during lactation if mothers are treated with infliximab can have significant adverse consequences [324,325,326]. Breastfeeding women may choose to forgo medical treatment, decide not to breastfeed, or delay infant immunization. Such decisions could result in missed or delayed crucial vaccinations during the early years of a child’s life, potentially increasing the risk of serious infections [312].
13. Surgery
13.1. In CD, Surgery Always Represents the Failure of Medicine and Is Only Indicated When Medical Treatments Fail
13.2. In Patients with Acute Severe UC, Surgery Should Be Delayed as Much as Possible
13.3. Most Drugs Used in IBD Treatment (Corticosteroids, Thiopurines, Biologics, and Small Molecules) Equally Increase the Risk of Postoperative Complications
13.4. Previous Failure with an Anti-TNF Agent Necessarily Warrants Switching to a Drug with a Different Mechanism of Action (Such as Vedolizumab or Ustekinumab) to Prevent Post-Operative Recurrence of CD after Surgery
14. Conclusions
Author Contributions
Funding
Data Availability Statement
Conflicts of Interest
Abbreviations
References
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Gisbert, J.P.; Chaparro, M. Common Mistakes in Managing Patients with Inflammatory Bowel Disease. J. Clin. Med. 2024, 13, 4795. https://doi.org/10.3390/jcm13164795
Gisbert JP, Chaparro M. Common Mistakes in Managing Patients with Inflammatory Bowel Disease. Journal of Clinical Medicine. 2024; 13(16):4795. https://doi.org/10.3390/jcm13164795
Chicago/Turabian StyleGisbert, Javier P., and María Chaparro. 2024. "Common Mistakes in Managing Patients with Inflammatory Bowel Disease" Journal of Clinical Medicine 13, no. 16: 4795. https://doi.org/10.3390/jcm13164795