Insights From Dr Alan Moss: Challenges With IBD Treatment
An estimated 1.3% of adults in the United States were diagnosed with inflammatory bowel disease (IBD) in 2015, according to the Centers for Disease Control and Prevention (CDC).1 The cause of IBD is not yet known, and several types of medications for IBD are currently available, so creating a treatment plan can be difficult.
Dr Alan Moss, MD, FACG, associate professor of medicine at Harvard Medical School, recently discussed challenging IBD cases he has encountered, as well as the appropriate way to approach them, during his session “Challenging Cases in IBD” at Harvard Medical School Gastro 2018 in Boston, Massachusetts. Herein, we ask Dr Moss our burning questions about challenging IBD treatment.
Consultant360: Your session was about challenging cases in IBD. Which patient populations present as challenges and why? And how can practitioners overcome these challenges?
Dr Alan Moss: The 2 main challenges that commonly occur in practice are how to deal with patients who lose response to biologics, and how to deal with complications that occur while taking biologics. I frequently contribute expert opinion about portals hosted by the American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA), and these are common management problems that gastroenterologists in the community post.
C360: Can you give us a short case example of a “challenging” patient, and how you worked through it?
AM: A recent example I highlighted is how to approach treatment when a patient has recently received a live attenuated vaccine or needs to get one while taking a biologic. The immune response to vaccines typically takes 2 weeks to occur in order to develop “immunity,” so I recommend that immunosuppressants are not started during this window. We know from a few studies that immunity to any vaccine in patients taking biologics is often lower than in healthy patients.
The second scenario, where someone taking a biologic is advised to get a live vaccine is controversial. Although the CDC recommends against live vaccines in patients who are immunosuppressed, it is unclear how existing and new biologics impact the risk of acquiring an active infection from a live vaccine. In one study, patients immunized against herpes zoster while on anti-TNFs did not have a greater risk for herpes zoster infection.
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C360: As with many gastrointestinal disorders, depression and anxiety are common comorbidities associated with IBD, especially among young patients. What psychological interventions can be implemented in these patients?
AM: This is an area we under-appreciate and probably under-treat. The Crohn’s & Colitis Foundation recommends that patients undergo some screening for depression annually, using a screening tool such as PHQ-9. In some patients, all that may be needed is a strategy from a psychologist to deal with stress associated with IBD. However, other patients may need more intensive care with a psychiatrist. Social networks and support are important to help deal with these chronic illnesses.
C360: What do you hope practitioners took away from your session?
AM: I hope the audience saw some cases in which they received confirmation that their approach has been correct and other cases in which they learned a small nugget of advice when a particular issue comes up in practice.
—Danielle Schipani
References:
- Inflammatory bowel disease (IBD). Centers for Disease Control and Prevention. Updated April 23, 2018. https://www.cdc.gov/ibd/data-statistics.htm. Accessed June 19, 2018.
- Moss A. Challenging cases in IBD. Presented at: Harvard Medical School Gastro 2018; June 11-14, 2018; Boston, MA.