Top Clinical Pearls for Managing Ulcerative Colitis

Dr Laura Raffals discusses her top clinical tips for ensuring proper diagnosis, treatment, monitoring, and management of patients with ulcerative colitis.

Laura Raffals, MD, is vice chair of Gastroenterology & Hepatology and professor of medicine at the Mayo Clinic in Rochester, Minnesota.

TRANSCRIPT:

Hi. I am Laura Raffals. I am a physician at the Mayo Clinic in Rochester, Minnesota, and I'm excited to share my top clinical pearls for managing patients with ulcerative colitis. The first pearl that I think is incredibly key is to make sure that you make an accurate diagnosis early. So unfortunately, we have learned that patients over the past 25-plus years often will go at least a year before they get an accurate diagnosis after they've started experiencing symptoms from their IBD, and we've made no progress in getting better at making a diagnosis early. So it's really critical to recognize symptoms that would be red flags suggesting a patient might have IBD. But when we see those red flags, we need to think about IBD and make an accurate diagnosis early.

That leads me to my second clinical pearl, which is, it's really important when you make a diagnosis to also recognize what the patient's prognosis is. The prognosis matters because that's going to ultimately help determine what treatment the patient should be on. So you need to recognize if a patient is likely to have a mild course of disease for the long haul, in which case you can look at treating that patient with something such as mesalamine. But if a patient has factors that might suggest their disease is going to be aggressive or that they may have complications from their disease, you need to use a more advanced therapy to get that disease under control. So know the prognosis of your patient. Pay attention to the clinical factors that patient presents with so you can get your patient on the right treatment.

The third pearl is we really need to target our therapy to mucosal healing. So back when I was a fellow, we often just wanted to get our patients feeling better. We wanted to get them off steroids. That's no longer as acceptable. Those things are important, but we also want to have objective evidence that we are healing the patient's colon, in which case that will prevent complications down the road.

That leads me to my next pearl, which is not to undertreat. Sometimes, our providers and even patients are very scared of potential side effects that our more advanced therapies may be associated with. But the reality is there are a lot of potential complications from undertreated disease. So you don't want to undertreat your patients and get them on appropriate therapy. So be educated about the risk and benefits of our treatments and don't undertreat.

The next pearl is you want to ensure that you give your treatments enough time to be effective. So a lot of times people will recognize that their patients are still symptomatic, still having issues, maybe a month or two into treatment, and then they jump ship and move to another mechanism of action. You don't want to let perfect be the enemy of good. You want to give your patients some time, give these drugs some time to work. The key is you want to see that patients are moving in the right direction, and then allow those drugs ample time to do their job. You don't want to let patients stall and remain on steroids for a long time, but you also do need to recognize that if a patient's improving and tapering off their steroids, sometimes you just need to be patient and give drugs enough time to do their job.

The next pearl is don't mistake symptoms for inflammation. This is critical. A third of our patients with IBD have underlying irritable bowel syndrome. And there are a lot of other things that could also cause symptoms that's not related to inflammation. So if a patient presents with symptoms, you need to document. And let's say you've documented that that patient has no inflammation. You need to think about what other causes could explain that patient's symptoms. And ulcerative colitis specifically in a healed colon that's been chronically inflamed, you can get fibrosis of the colon. And particularly this is key in the rectum because you may lose compliance, which can lead to symptoms. These patients could get pelvic floor dysfunction due to longstanding issues with diarrhea. And also, infection, another thing that can cause symptoms, C. diff, CMV. So don't mistake symptoms for inflammation.

My next pearl is opioids are not a good treatment option for managing pain in our IBD patients. For our IBD patients, there are very few times when opioids are appropriate. In ulcerative colitis, it's hard to imagine when that appropriate time might be. So you should not be using opioids in an ulcerative colitis flare. Getting control of disease is the appropriate strategy for managing pain in ulcerative colitis. You can use alternative strategies to manage pain. Acetaminophen is safe. For chronic pain, even consider using antidepressants, other neuromodulators, reaching out to psychology pain centers to get help in managing pain. But opioids are not a safe treatment for pain in your IBD patient.

The next pearl is do not forget about DVT prophylaxis in a patient who is hospitalized with ulcerative colitis. So we recognize that up to a third of patients with IBD, ulcerative colitis who are hospitalized are not on prophylactic anticoagulation, and their risk is more than 3-fold higher of developing a DVT or PE compared to the general population. So these patients need to be on prophylactic anticoagulation, and it's safe to do that even if they're having bloody diarrhea. So prophylactic anticoagulation for those patients.

My last clinical pearl, but probably the most important clinical pearl, is the management of any IBD patient is a team sport and you need to take advantage of the multidisciplinary team to provide the best care you can for your patients. So don't try to do this on your own. Bring in your colleagues from all the other disciplines that are critical to managing our patients with IBD and ensuring that they have the best quality of life and the best outcomes we can hope for. So thank you.