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Crohn’s Disease: My Tips on Managing Flares and Offering Preventive Care

Crohn’s Disease: My Tips on Managing Flares and Offering Preventive Care Posted By:
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Crohn’s disease (CD) is a lifelong, progressive condition that affects all age groups. NPs and PAs have an important role in managing patients with CD, including monitoring symptoms and response to treatment, screening for cancer or other complications, and providing vaccinations and other preventive care. 

Assessing Patients With Crohn’s Disease for Flares
There is a lot of overlap between active inflammatory bowel disease (IBD) and symptoms of functional bowel disease or irritable bowel syndrome (IBS), and it can be challenging to distinguish between them. So, when a patient with CD presents to their provider with symptoms such as diarrhea, fever, or fatigue, how do we know if this is a CD flare that may necessitate further testing or a change in therapy?

The best way to assess for flares is to see the patient in person and build a clear picture of the extent of their disease. Where is the site of their CD? Is it in the terminal ileum and right colon, or elsewhere? Does the patient have a history of fistulizing disease, any perirectal or perianal abscesses, or strictures?

History taking should focus on the changes the patient has noticed. Are they having more fatigue or abdominal pain? Is there any increase in the frequency of bowel movements or any rectal pain or leakage? Review the patient’s last colonoscopy or imaging and recent laboratory results to compare with the current presentation. Has there been a change in their weight? Is there any anemia or a drop in their hemoglobin from their baseline level?

Targeted laboratory studies that I order at this stage would typically include a complete blood count, C-reactive protein, and definitely a fecal calprotectin or fecal lactoferrin. Calprotectin gives a good indication of the degree of mucosal inflammation, which helps pinpoint whether the patient’s symptoms are due to a relapse in their CD or to something else. If the inflammatory markers are elevated, and perhaps there is a palpable mass in the right lower quadrant in a patient with terminal ileal disease, the next step would be further imaging before you consider a change in therapy, such as increasing the dose or adding a short-term course of corticosteroid, or an antibiotic before changing any biologic therapy. If the patient has fistulizing perianal disease, a perianal inspection is needed. Assessing disease flares is much easier to do in person, combined with a physical examination. 

When to Repeat Endoscopy or CT/MR Imaging
The ultimate goal of treatment for CD is to achieve mucosal healing. Although many patients will report feeling much better after beginning treatment, symptom improvement is not in itself evidence of mucosal healing. There may still be a need for a further change in therapy until healing is confirmed.

The method of confirming mucosal healing depends on the site of disease. For patients with terminal ileal, right colon disease, the usual approach is to repeat a colonoscopy with biopsy to look for mucosal healing. If, however, there is small bowel disease that is not within reach of the colonoscope, then cross-sectional imaging will be needed; use of magnetic resonance (MR) enterography will reduce exposure to ionizing radiation, which should be prioritized, particularly in younger patients.

Vaccine Considerations for Patients With CD
Immunization rates among people with IBD are low, despite these patients being at greater risk for vaccine-preventable illnesses. Live-virus vaccines should be avoided when patients are immunosuppressed or starting immunosuppressive therapy soon (including high-dose prednisone). This means it is important for patients with CD to catch up with recommended vaccinations before beginning biologic therapy, especially for vaccines that may involve a live attenuated virus, such as varicella and MMR.

The Advisory Committee on Immunization Practices (ACIP) recommends vaccination against HPV at age 11 or 12 and catch-up vaccination up to the age of 26 years. This is a recombinant virus and is recommended for patients with IBD. It is advised to plan a vaccination schedule with patients well in advance of requirement, such as for travel abroad. Yellow fever vaccination, for example, is a live attenuated vaccine and is contraindicated in people receiving immunosuppressive therapy.

Modern electronic medical record systems allow healthcare professionals to keep track of our patients’ vaccination records and ensure these can be easily shared between primary care and the local gastroenterologist so that no patient slips through the net.

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Filed under: Gastroenterology , NPs & PAs

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