Corey Siegel, MD, on Managing Symptoms While Treating to Target

Dr Siegel discusses his presentation at the virtual Advances in Inflammatory Bowel Disease regional meeting on therapies that can help control manage the symptoms of inflammatory bowel disease while executing a treat-to-target strategy.

Corey Siegel, MD, is section chief of gastroenterology and hepatology at the Dartmouth-Hitchcock Medical Center and professor of medicine at the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire.
 

See Dr Siegel and Dr Jessica Salwen-Deremer discuss sleep disturbance in inflammatory bowel disease here.

TRANSCRIPT:

Hi. This is Dr. Corey Siegel from the Dartmouth‑Hitchcock Medical Center in Lebanon, New Hampshire where I'm the section chief of gastroenterology and a professor of medicine at the Geisel School of Medicine at Dartmouth.

Today at the AIBD regionals, I talked about while treating to target, what therapies can we get our patients to manage their symptoms. I chose the topic for a few reasons.

First, our patients may have persistent GI symptoms after we reach our targets, but we also know that reaching our targets isn't easy. Even in the best clinical trials like CALM that were completely focused on going after mucosal healing, we're still not achieving our goals in about 50% or more of patients.

Therefore, while working very aggressively and intensively to use our best medications to treat to our mucosal and histologic targets, we also need to think about treating our patients' symptoms that may be dependent on or independent of their active inflammation.

If you think about what's important to patients, they're not really thinking about mucosal healing and histologic healing—that's more on us—what they're thinking about are their symptoms.

What can we do to manage diarrhea, urgency and incontinence, bloating and gas, abdominal pain, and fatigue amongst many others while we're continuing to really push on our most effective therapies?

For treating diarrhea, you first have to think about is this in fact from their inflammation or is it something else. Could it be an infection? The general rule is let's evaluate what might be the underlying cause. Let's look for signs of inflammation. Let's look for signs of infection. Treat as appropriately as we can, and if we're not finding significant inflammation, treating symptomatically with antidiarrheals is perfectly OK, as we also might need to consider treating with bile salt binders, antibiotics, and other symptomatic treatment controls.

Corticosteroids aren't completely taboo. We want to keep our patients off of prednisone, but sometimes a short course of prednisone, while taking calcium and vitamin D with a clear escape plan for what to do after prednisone, can be a safe strategy to quickly manage our patients' symptoms, get them back on track, and buy a little more time for more effective therapies to work.

If there are no signs of inflammation, we talked about things like bile salt binders, small intestinal bacterial overgrowth, and other strategies to treat carbohydrate intolerance or even IBS-D, which our patients can also have, while also dealing with inflammatory bowel disease.

Whether it's a postinflammatory state or an independent process, we need to think about these and others like celiac disease, hyperthyroidism that sometimes we can miss if we're too focused on our underlying IBD.

Abdominal pain is really challenging. There have been a number of analyses and a recent Cochrane Review that looked at all of the treatments for abdominal pain in the setting of IBD, and unfortunately, we really have some gaps in what we know from a data standpoint on what might be helpful to patients and safe.

A lot of patients and our colleagues bring up the use of cannabis to treat abdominal pain. It probably does work, and it's not an unreasonable adjunct to treating the underlying disease as well. It probably keeps our patients off of opioids, which is even more important, but still a lot more to learn about how cannabis works and is it safe long‑term and even short‑term for our patients.

Finally, I touched on fatigue, and this is a really big and difficult problem. It's easy to blame fatigue on everything related to IBD with good reason, but patients can also be fatigued even when we treat their inflammatory bowel disease effectively. We need to think about what might be causing this beyond just their IBD. So after looking and treating inflammation aggressively, look for reversible factors like anemia, iron deficiency, B12 and thiamine deficiency, and even vitamin D deficiency can lead to this. Easily, quickly treatable, and reversible are deficiencies can be extremely helpful and appreciated by our patients.

Think about steroid withdrawal. Is there some relative adrenal insufficiency that needs to be treated? Sleep is also something we should be asking our patients about that certainly can be involved in fatigue. We've learned now from work in this field, including work from one of my colleagues here, Dr. Jessica Salwen‑Deremer, that sleep and IBD are closely associated. The worse somebody sleeps, perhaps it leads to more inflammation, and the more inflammation they have, might interrupt their sleep. Of course, all this can lead to fatigue, so please ask your patients about their sleep and see if it's something that needs to be addressed.

In summary, although while we're working to treat‑to‑target and heal our patients' bowels, we also need to think about their symptoms, and we need to treat their symptoms that are either dependent on inflammation or perhaps independent of inflammation.

Thinking about these individual symptoms, asking our patients what really bothers them most, using treatments that may not be IBD treatments but treatments for symptomatic control of GI problems can be highly appreciated by our patients, and we'll hopefully get them through to a point that we can get them healed where many of these symptoms eventually will go away.

Thank you for your time.   

Siegel C. While treating to target, what therapies can we give our patients to manage their symptoms? Presented at: Advances in Inflammatory Bowel Disease 2022 Regional Meeting; March 5, 2022; Virtual.