Concurrent Infections in Inflammatory Bowel Disease Flares

Briefly noted: Y Hanada et al. Clin Gastroenterol Hepatol 2018; 16: 528-33.

In this retrospective review with 9247 patients with IBD, the incidence of bacterial pathogens (non-C diff) identified was <3% of those who were tested; in this group (n=25), Aeromonas was detected in 8,Salmonella in 7, Plesiomonas in 4, Campylobacter in 2, and Yersinia in 2.  From authors: “These infections did not have a significant negative impact on patient outcomes.  Given these findings, routine testing for infections other than CDI is not recommended.”

Chattahoochee River

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Gut-Brain Modulators for Functional GI Disorders: Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome

A lengthy report (DA Drossman et al. Gastroenterol 2018; 154: 1140-71) thoroughly reviews the evidence for neuromodulators for functional GI disorders, including Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome.

“Some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship.”

The report makes specific recommendations for several functional conditions (Table 4).

  • For dyspepsia, the authors recommend categorizing as either postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) as per Rome IV criteria.
  • They state that “Buspirone…may be used for PDS where early satiety, fullness and nausea predominate.”
  • “Mirtazapine is a good treatment option for PDS when there is chronic nausea and vomiting, or weight loss, and it may also help coexisting abdominal pain.”
  • For EPS, “studies mainly support the use of TCAs, either initially or after an unsuccessful response to a proton pump inhibitor.”

Figure 5 outlines general treatment advice:

  • SSRIs -“when anxiety, depression and phobic features are prominent with FGIDs”
  • TCAs -“first-line treatment when pain is dominant in FGIDs”
  • Tetracyclic antidepressant (mirtazapine, mianserin, trazodone) -“treatment of early satiety, nausea/vomiting, weight loss and disturbed sleep”
  • SNRIs (duloxetiine, venlafaxine, desvenlafaxin, milnacipran) -“treatment when pain is dominant in FGIDs or when side effects from TCAs preclude treatment”
  • Augmentation therapies are subsequently delineated including atyipical antipsychotics, pyschological treatments (like cognitive behavioral therapy) and hypnosis

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

NY Times: Financial Bill of Rights for Patients

NY Times: Nine Rights Every Patient Should Demand

This article addresses a fundamental problem in medicine: lack of price transparency, and the complexity of understanding health care expenses..

The right to an itemized bill in plain English.

  • Patients can’t detect and dispute improper charges if their bills involve dozens of pages of medical abbreviations. Studies have found that 30 percent to over 50 percent of hospital bills contain errors…

The right to never receive a surprise out-of-network bill.

The right to accurate information about the provider network in my insurance plan.

  • Doctors … must be in-network for all the procedures they normally perform and on all days of the week they practice. If a provider is listed as in-network but is not, the insurer should take care of the charge.

The right to a stable network.

  • I buy my insurance policy for a year. If my doctor or insurer stops participating in my network within that year or in the midst of treating me for an acute disease, I should still be billed as an in-network patient.

The right to be informed of conflicts of interest.

  • Patients should know if their doctors own a financial stake in a testing or procedure facility before a test or procedure is ordered or scheduled…

The right to be informed in advance about any facility fees.

  • A procedure can come with different price tags depending on where it is performed…

The right to see a price list for elective procedures.

The right to be informed of cheaper options.

  • Many doctors recommend the most expensive course of care and don’t tell patients that there are other options…

The right to know that a disputed bill will not be sent to a collection agency.

  • The threat of dealing with bill collectors and a damaged credit rating is used to intimidate patients into paying up without asking questions…

I know these rights might seem like a fantasy in our current system, with its overwhelming complexity and cost. But they are actually quite similar to the rights we expect in any other sector of our economy. 

My take: The way we pay for health care does not make sense.  Understanding costs for medical care should be like reading the nutrition label boxes.  Currently, even an expert in health care has difficulty understanding what costs to expect.

Algorithm for “Cursed” Dyspepsia

A recent review (P Koduru et al. Clin Gastroenterol Hepatol 2018; 16: 467-79) provides a good review of dyspepsia and in addition provides some literary perspective.

In their introduction, the authors quote James Joyce in Ulysses: “Tom Rochford split powder from a twisted paper into the water set before him –That cursed dyspepsia, he said before drinking. –Breadsoda is very good Davy.”

After reviewing the definition and the pathophysiology, the authors provide a suggested algorithm (Figure 2).

Initial options:

  • In areas with high H pylori, there is an option of “test and treat” and relying on endoscopy in those who fail to respond
  • Empiric PPI therapy which works best if reflux-type symptoms are present and relying on endoscopy in those who fail to respond
  • Endoscopy without empiric treatment

In those with a negative endoscopy –>functional dyspepsia treatment is driven by symptoms:

  • If pain, the first line option recommended is a tricyclic antidepressant (pain modulator)
  • If nausea, the first line option recommended is an antiemetic
  • If early satiety, the first line option recommended is buspirone

For those with resistant and disabling symptoms, “consider nonpharmacologic approaches, such as psychotherapy or acupuncture.”

Related posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

HBV Reactivation Risk with HCV DAA Therapy and What to Do About It

A recent prospective study (C-J Liu et al. Gastroenterol 2018; 154: 989-97) provided some reassurance about the likelihood of hepatitis B virus (HBV) reactivation during hepatitis C virus (HCV) treatment with direct-acting antivirals (DAA).

In this study with 111 patients with both HCV and HBV treated with ledpasvir/sofusbuvir, all (100%) of the patients had a sustained virologic response for their HCV infection. Other key findings:

  • Of the 37 patients with baseline HBV DNA < 20 IU.mL, 31 (84%) developed detectable HBV DNA levels through posttreatment week 12.
  • Of the 74 patients with baseline HBV DNA >20 IU/mL, 39 (53%) developed increases in HBV DNA >1 log10 IU/mL through posttreatment week 12.
  • 5 patients developed ALT >2 times ULN and 3 patients were started on HBV therapy.

The associated editorial (pgs 795-8) made the following recommendations:

  • “HBsAg-negative/HBcAb-positive patients should be monitored with ALT alone until SVR12 and should be tested with HBsAg +/- HBV DNA only if ALT increases or fails to normalize on therapy.”
  • “HBsAg-positive patients with undetectable baseline HBV DNA should be considered for preemptive anti-HBV treatment, or monitored with ALT and HBV DNA until SVR12”
  • “HBsAg-positive patients with positive baseline HBV DNA should be started on preemptive anti-HBV treatment until SVR12.”

Using the above management strategy will limit the number of HBV-infected patients who need to be treated.

My take: This study and the associated editorial provide useful information regarding DAA in coinfected HBV/HCV patients; this is important for patients and practitioners, especially given the black box warning on DAA medications.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.