Ulcerative Colitis

High Specialist Engagement Can Curb Mistakes in Severe UC

Specialist engagement can help minimize mistakes that put patients with acute severe ulcerative colitis (UC) at high risk for life-threatening situations, according to a presentation at the 2018 AIBD Meeting.  

 

One of the most important mistakes a gastroenterologist can make is misdiagnosis, according to Corey Siegel, MD, MS, chief of gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center and associate professor of medicine at Geisel School of Medicine at Dartmouth College.

 

“You can get down the wrong path early if we don’t initially question the diagnosis and make sure we aren’t missing something else or mistaking it for something else,” Siegel said during his presentation.

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Gastroenterologists should keep the following in mind to avoid mistakes in treatment:

 

  • have the patient meet the surgeon and STOMA nurse around time of admission;
  • test for tuberculosis early to avoid delays in treatment;
  • early and easy sigmoidoscopy is key;
  • do not give steroids too much of a chance; a patient is unlikely to get more benefit from IV steroids beyond 3 to 5 days;
  • do not wait too long to give rescue therapy and ensure it is the proper dose; day 3 is when assessment should be made, not waiting for steroids to “kick in”;
  • prevent other complications including opportunistic infections, forgetting DVT prophylaxis, and misuse of narcotics for pain management; and
  • remember surgery is a treatment option.

 

Other components to remember are advocating for the patient with their outpatient payer coverage and being mindful of proper discharge techniques.

 

A practical challenge that can be encountered is denial of treatment by a payer. Siegel said he has experienced when the first dose of infliximab was administered to a patient, but then the payer denies the second dose since it is not first-line therapy.

 

A patient should not be getting one dose of a biologic drug and moving on, according to Siegel.

 

“Waiting for the denial to come is often a problem because it comes a day or two before a patient is due for that dose and you don’t want to delay second dose…They will ultimately agree [but] you need to explain why it’s so important to not give just one dose of one of the most effective drugs for UC then move onto something else,” Siegel said. Never give up on this, do not do it out of convenience, [but rather] stick to your guns and fight for the patients.”

 

There are no validated discharge criteria for hospitalized UC patients. To consider discharge, a patient must show markedly improvement, have less than 3 bloody bowel movements per day, outpatient medications, tolerate oral hydration and nutrition, and have a follow-up clinical appointment already scheduled for 1 to 2 weeks after discharge.

 

“There are a lot of things that can go wrong with these patients,” Siegel said. “I know I’ve made these mistakes, we all have.”

 

Reference:

Siegel C. Common Mistakes in the Treatment of Severe Ulcerative Colitis. Presented at: Advances in Inflammatory Bowel Diseases; December 13-15, 2018; Orlando, FL. https://www.consultant360.com/meetings/aibd.