6 common mistakes when treating patients with ulcerative colitis
ORLANDO — When a patient with ulcerative colitis is sick enough to be admitted to the hospital, the stakes can be incredibly high. In a presentation at Advances in IBD 2018, Corey Siegel, MD, of the Dartmouth-Hitchcock Medical Center, said there is little room for mistakes with these patients.
For his talk, Siegel sought the help of national and international experts in gastroenterology and surgery to find some of the most common mistakes physicians make when treating patients with severe UC.
Waiting too long to consult a surgeon
“Surgical consultation early is very important,” Siegel said. “I always tell my patient, ‘This doesn’t mean I think you need a surgery right now. It means I want you to meet the surgeon and hear the options.’”
Siegel said the ideal meeting with a surgeon occurs at the time of admission, so when big decisions need to be made, it is already out of the way.
In addition to this early surgical consultation, Siegel said it can be common for patient transfer to a referral center to be delayed.
“Mortality rates are affected by either being at a low-volume place that doesn’t do a lot of surgery for acute severe [UC], or waiting too long in the hospital,” Siegel said.
Treating the wrong disease
“We want to make sure we’re not being faked out by something else,” Siegel said. “Is this an infection like Clostridium difficile ... or other acquired infections?”
Siegel said it is important to ensure the patient is not suffering from another kind of ailment – such as ischemia, functional bowel disease, or anxiety – that can present with symptoms similar to UC. Patients can suffer damage from chronic UC that could lead to stricturing or dysmotility. When a few of these symptoms get stacked on top of each other, Siegel said it can begin to look like acute severe UC.
“You can get down the wrong path early if you don’t question the diagnosis and make sure we’re not missing anything else or mistaking this for something else,” Siegel said.
Giving steroids too much time
“IV steroids do not work for everybody,” Siegel said. “You shouldn’t assume that they’re going to get better if you just give them longer.”
Approximately 30% to 40% of patients with acute severe UC will fail to respond to steroids, and the patient’s response to steroids after 3 or 4 days will most likely predict whether the steroids will work at all.
Prolonged treatment with steroids will likely not offer patients any benefit. Siegel said previous studies have shown that high-dose steroid therapy beyond 7 to 10 days offers no additional value and could increase the rate of complications.
Delaying rescue therapy
“There are a number of reasons for this,” Siegel said, regarding delay of rescue therapy. “Hoping that steroids will kick in; the provider or patient is uncomfortable using biologic therapy; the hospital may be resistant to give because of costs; ... or you need approval from the hospital or payer.”
Siegel said the decision to give rescue therapy should be assessed at day 3 based on if the patient has more than eight stools per day or three to eight stools with a C-reactive protein level of more than 45 mg/L.
“When giving rescue therapy, we have to make sure we’re doing it right,” Siegel said. “Because taking a check swing in this situation and not really going for it, you may as well not give rescue therapy at all.”
Not preventing complications
“We may have treated them perfectly well with the exact, right timing of IV steroids, give them medication at the exact, right time,” Siegel said. But “there’s some other things that we have to think about with our patients.”
Siegel warned against several common problems, including forgetting about deep vein thrombosis prophylaxis and opportunistic infections, as well as not giving the patient proper nutrition.
“It’s compelling to [give them nothing by mouth],” Siegel said. “It decreases the frequency of stools, patients often times don’t want to eat, but this is not evidence-based.”
“As our patients get sicker and sicker, and really don’t want to have surgery, we understand clearly why that would be the case,” Siegel said.
However, he said it is important not to “save a colon at the risk of life.” Siegel stressed the necessity of surgery in some cases and warned physicians not to think of colectomy as a failure. - by Alex Young
Disclosure: Healio Gastroenterology and Liver Disease could not confirm Siegel’s relevant financial disclosures prior to publication.