mind and gut -...

【 1 】 EDMONTON, AB — SATURDAY, JUNE 10, 2017 — MIND and GUT

MIND and GUT The Conundrum of Chronic Illness

TABLE OF CONTENTS

Agenda and Objectives........................................................................................................................................................................................... 2

Faculty.................................................................................................................................................................................................................................. 3

CASE-BASED WORKSHOPS

• Case 1: Inflammatory Bowel Disease and Depression.................................................................................................... 4

• Case 2: Peri-partum Issues ............................................................................................................................................................... 7

Faculty Financial Interest Disclosure Summary.................................................................................................................................. 10


【 2 】SATURDAY, JUNE 10, 2017 — MIND and GUT — EDMONTON, AB

BACKGROUND There are links between the ‘Mind’ and the ‘Gut’ when dealing with chronic diseases such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Patients often search for alternative therapies to deal with their chronic pain and associated mental health issues. AIMS To bring together the members of the multi-disciplinary team who are involved in the daily care of people with IBS and IBD, in order to examine the importance of mental health issues in patients living with chronic illness.!

Participants in this program will:

1. Review IBD the and impact of chronic illness on patients

2. Examine the importance of mental health issues in patients with chronic illness

3. Explore strategies to manage chronic pain in patients with IBS and/or IBD

4. Examine alternative therapies patients can use to cope with chronic illness, including cognitive behavioural therapy (CBT), Traditional Chinese Medicine (TCM) and multidisciplinary team care approaches

AGENDA Time Session/Topic/Objectives Faculty

9:00 Introduction – Mind and Gut: Help your patient deal with chronic illness Vivian Huang

9:10 Seminar 1 – IBD Disease Activity: Physical and psychological effects Daniel Sadowski

9:30 Seminar 2 – Fatigue and IBD: My gut is normal – why I am still tired? Karen Kroeker

9:50 Seminar 3 – Chronic Pain and Chronic Illness: Beyond the opiates Dallis Westin

10:10 Refreshment Break

10:30 Seminar 4 – Cognitive Behavioural Therapy for Chronic Illness: Empower your patient to cope Glenda MacQueen

10:50 Seminar 5 – Mood Disorders and the (peri- and post-partum) Parent with IBD Dawn Kingston

11:10 Q&A Faculty Panel Discussion Speakers

11:30 LUNCH

12:15 Seminar 6 – Quality of Care: The multidisciplinary team approach to management of IBD Lisa Westin

12:35 Seminar 7 – Clinical and Translational Research: The future of IBD and the importance of community involvement Karen Madsen

12:55 Seminar 8 – Traditional Chinese Medicine Approach to IBD Steven Aung

13:15 Workshop Case from the Podium: Traditional Chinese Medicine Facilitator: Vivian Huang

13:35 Refreshment Break

13:50 Workshop Case Breakouts: Putting it into practice Facilitators

14:30 Expert panel discussion of cases Speakers

14:10 Closing remarks Vivian Huang

SATURDAY, JUNE 10, 2017 — MIND and GUT — EDMONTON, AB【 3 】


Co-Chairs

Richard N. Fedorak, MD FRCPC FRCP (London) FRCS Dean, Faculty of Medicine and Dentistry Professor of Medicine Division of Gastroenterology University of Alberta Edmonton, AB

Vivian Huang, MD MSc FRCPC Assistant Professor of Medicine Preconception and Pregnancy in IBD Clinical Research Program, Division of Gastroenterology University of Alberta Edmonton, AB

Faculty

Steven Aung, MD FRCPC Clinical Professor Faculty of Medicine and Dentistry Director of Community Engagement Integrative Health Institute University of Alberta Edmonton, AB

Robert J. Bailey, MD FRCPC Clinical Professor of Medicine, University of Alberta Royal Alexandra Hospital Medical Director, North Health Services Network Edmonton, AB Dawn Kingston, RN MN PhD Associate Professor Department of Nursing University of Calgary Department of Obstetrics and Gynecology University of Alberta Edmonton, AB Karen I. Kroeker, MD, MSc, FRCPC Assistant Professor Program Director, Gastroenterology Director, Inflammatory Bowel Disease Clinic Gastroenterology University of Alberta Edmonton, AB Allen WK. Lim, MD FRCPC Clinical Lecturer Gastroenterology, University of Alberta Misericordia Hospital Edmonton, AB

Glenda MacQueen, MD PhD FRCPC Professor, University of Calgary Vice Dean, Cumming School of Medicine University of Calgary Calgary, AB

Karen Madsen, PhD Co-Director, The Centre of Excellence for Gastrointestinal Inflammation and Immunity Research Professor, Division of Gastroenterology University of Alberta Edmonton, AB Daniel C. Sadowski, MD Professor, Division of Gastroenterology University of Alberta Attending Staff Royal Alexandra Hospital Edmonton, AB Jesse Shaalan Siffledeen, MD FRCPC MSc (Oxon) Associate Clinical Professor of Medicine Division of Gastroenterology University of Alberta Covenant Health/Grey Nuns Hospital Edmonton, AB Dallis Westin, MA RPsych Psychologist, Westin Psychology Edmonton, AB Lisa Westin, RN MN CGNC GI Case Manager Red Deer Regional Hospital Red Deer, AB



CLINICAL CASE STUDY Inflammatory Bowel Disease and Depression A 26 year-old female with stricturing ileal and rectal Crohn's disease, diagnosed at age 14.

• Ileal resection (2006)

• Sigmoid colonic resection (2008)

• Loss of response to adalimumab (2011) and infliximab (2016), due to development of anti-drug antibodies

• Significantly bothered by high frequency bowel movements and urgency affecting relationships and her ability to hold down a job

• Patient cannot tolerate bile acid sequestrants and not adherent with bulking agents

• Claims to be intolerant of thiopurines

Discussion Points

1. Does she have active Crohn’s disease?

2. What investigations would you order?

• C-reactive protein (CRP): 30.5 mg/mL

• Hemoglobin (Hb): 105 g/L

• Mean corpuscular volume (MCV): 75 fL

• Ferritin: 4 pmol/L

• Fecal calprotectin (FCP): 350 µg/g

• Colonoscopy: Progressive stricturing ileal and anorectal disease

Discussion Point

3. What risk factors could she have for losing response to the biologic medications?

• Was not adherent to combination immunosuppressive therapy (often used to reduce risk of developing anti-drug antibody formation)

• Actively smoking and unable to quit due to social stressors and peers

Case Evolution

Persistent flattened affect, though responds with anxiety (irrational fears of cancer) at the thought of being placed on dual immunosuppression, or systemic corticosteroids



Discussion Point

4. What possible reasons could she have for non-adherence or anxiety against dual immunosuppression or corticosteroids?

Case Evolution

Intolerant of systemic corticosteroids previously (manic episodes in 2008, with significant depression following discontinuation, prompting the illicit use of cocaine that she continued to use

Discussion Point

5. What comorbid psychiatric disorder or factors should we be aware of in managing this patient’s IBD?

• Major depressive disorder diagnosed in 2016, after long discussion with gastroenterologist, and with confirmation from general practitioner

• Patient admits inability to cope with health (major contributor to depression), and exhibits several symptoms of concern

Discussion Point

6. What would you recommend for this patient, to help with medication adherence, with coping with disease?

• Ultimately, psychiatric counseling and anti-depressant therapy (SSRI) are initiated by her GP

Case Evolution

Patient's mental health responds well to this therapy resulting in much better adherence to IBD therapy (re-starts thiopurine and initiates ustekinumab)

Good response to dual immunosuppression therapy, with endoscopic evidence of remission for the first time since diagnosis

Bowel habits, though not appreciably different (5–7 BM daily), are more manageable by the patient

Illicit drug use has stopped, and patient has stable employment



References 1. Gracie DJ, Williams CJ, Sood R, et al. Poor Correlation Between Clinical Disease Activity and Mucosal Inflammation, and the Role of Psychological Comorbidity, in

Inflammatory Bowel Disease. Am J Gastroenterol. 2016 Apr;111(4):541–51.

2. Bressler B, Panaccione R, Fedorak RN, et al. Clinicians’ guide to the use of fecal calprotectin to identify and monitor disease activity in inflammatory bowel disease. Can J Gastroenterol Hepatol. 2015;29(7):369–72.

3. Sexton KA, Walker JR, Graff LA, et al. Evidence of Bidirectional Associations Between Perceived Stress and Symptom Activity: A Prospective Longitudinal Investigation in Inflammatory Bowel Disease. Inflamm Bowel Dis. 2017;23:473–83.

4. van der Have M, Oldenburg B, Kaptein AA, et al. Non-adherence to Anti-TNF Therapy is Associated with Illness Perceptions and Clinical Outcomes in Outpatients with Inflammatory Bowel Disease: Results from a Prospective Multicentre Study. J Crohns Colitis. 2016 May;10(5):549–55.

5. Coenen S, Weyts E, Ballet V, et al. Identifying predictors of low adherence in patients with inflammatory bowel disease. Eur J Gastroenterol Hepatol. 2016 May;28(5):503–7.

6. Fuller-Thomson E, Lateef R, Sulman J. Robust Association Between Inflammatory Bowel Disease and Generalized Anxiety Disorder: Findings from a Nationally Representative Canadian Study. Inflamm Bowel Dis. 2015;21:2341–48.

7. Mikocka-Walus A, Knowles SR, Keefer L, et al. Controversies Revisited: A Systematic Review of the Comorbidity of Depression and Anxiety with Inflammatory Bowel Diseases. Inflamm Bowel Dis. 2016;22:752–62.

8. Lofland JH, Johnson PT, Ingham MP, et al. Shared decision-making for biologic treatment of autoimmune disease: influence on adherence, persistence, satisfaction, and health care costs. Patient Preference and Adherence. 2017;11:947–58.

9. Kariburyo MF, Xie L, Teeple A, et al. Predicting Pre-emptive Discussions of Biologic Treatment: Results from an Openness and Preference Survey of Inflammatory Bowel Disease Patients and Their Prescribers. Adv Ther. 2017 May 8. doi: 10.1007/s12325-017-0545-4. [Epub ahead of print]



CLINICAL CASE STUDY Preconception UC Patient on 5-ASA and Immunomodulator Medication A 26-year-old woman with ulcerative colitis is considering pregnancy.

She is on 5-ASA 4g po daily, azathioprine 150mg po daily, and a biologic (anti-TNF therapy) for her ulcerative colitis. She currently has 4 loose stools daily with intermittent bleeding. Her abdomen is soft, with slight tenderness in the left lower quadrant. She is concerned about whether and when she can get pregnant.

Discussion Points

1. How would you counsel the patient regarding the effect of disease activity on fertility and pregnancy?

2. What tests should be arranged to assess preconception disease activity?

Case Evolution

Clinical disease activity score:

• Partial Mayo Score (Mayo): 4

Laboratory blood tests:

• Hemoglobin (Hb): 105 g/L

• White blood cell (WBC) count: 4.6 x 109/L

• Platelet count: 235 x 109/L


• Iron: 20 μmol/L

• Total iron-binding capacity: Normal

• C-reactive protein (CRP): 25 mg/mL

Stool tests:

• Clostridium difficile: negative

• Culture & sensitivity: negative

• Fecal calprotectin (FCP): 1000 µg/g

• Colonoscopy: severe left sided colitis (30cm)

Discussion Points

3. How would you treat her left-sided active colitis?

4. What would you advise regarding her plans to become pregnant at this point in time?



Case Evolution

The patient admitted to not taking her full dose of 5-ASA medication. She was taking only 2 tablets (1g) daily. She stopped her azathioprine therapy several months prior. She has missed a few doses of her biologic therapy in the past months.

Discussion Point

5. How do you address her non-adherence to therapy? Her concerns about IBD medications in pregnancy?

Case Evolution

You increase her 5-ASA dose to 4g daily, and add topical 5-ASA enemas nightly x 30 days. In discussion with the patient, and based on evidence and recommendations, she refuses to restart azathioprine, but agrees to be more adherent to the biologic therapy.

She returns to your office 5 months later in full clinical remission, indicating she is ~13 weeks pregnant. She would like to stop her medications, including the biologic therapy, as she is feeling better and wants to minimize any drugs exposed to the baby.

• pMayo: 1

• Hb: 115 g/L

• WBC: 4.3 x 109/L

• Platelet count: 245 x 109/L


• Iron: 25 μmol/L

• TIBC: Normal

• CRP: 5.2 mg/mL

• FCP: 150 µg/g

Discussion Points

6. What pregnancy-related concerns do you have? Is she considered “high risk”?

7. What do you advise her about her IBD medications? Should she stop them in pregnancy?



8. What do you advise her about the biologic therapy? Can she stop?

Case Evolution

You continue the oral 5-ASA and the anti-TNF biologic medication. She is referred to the high-risk obstetrics program at your hospital, where she is monitored with perinatal ultrasounds and assessments for fetal growth.

Discussion Point

9. How do you address her concerns about IBD medications in pregnancy?

Case Evolution

Her biologic therapy is adjusted to time the last dose in third trimester that she receives at 32 weeks gestational age. She is planned for a vaginal delivery. However, due to slow progression of labour, she requires a cesarean delivery. The C-section goes well, and she has no complications. The baby weighs 7 lb 3 oz and is healthy!

Discussion Points

10. What adjustments, if any, should be made regarding her medications after delivery?

11. She would like to breast-feed. How would you counsel her about the use of 5-ASA and Imuran medications during lactation?

References 1. Nguyen GC, Seow CH, Maxwell C, et al. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology. 2016

Mar;150(3):734–57.e1. doi: 10.1053/j.gastro.2015.12.003. Epub 2015 Dec 11.

2. Julsgaard M, Hvas CL, Gearry RB, et al. Fecal Calprotectin Is Not Affected by Pregnancy: Clinical Implications for the Management of Pregnant Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis. 2017;0:1–7.

3. Bálint A, Berényi A, Farkas K, et al. Pregnancy does not affect fecal calprotectin concentration in healthy women. Turk J Gastroenterol. 2017;28:171–5.

4. Seow CH, Leung Y, Vande Casteele N, et al. The effects of pregnancy on the pharmacokinetics of infliximab and adalimumab in inflammatory bowel disease. Aliment Pharmacol Ther. 2017;45:1329–38.

5. Abhik R, Chambers CD, Martin C, et al. Exposure to Biologic Therapy and Childhood Development among Offspring of Women with Inflammatory Bowel Disease: Results from the Piano Registry. Gastroenterology. April 2017;152(5):S85–86.



FACULTY FINANCIAL INTEREST DISCLOSURE SUMMARY

To ensure balance, independence, objectivity, and scientific rigour in all educational and scientific activities, the faculty participating in this educational event are expected to disclose to the audience any significant financial interest or other relationships. The intent of this initiative is to provide members of the audience with information on the speaker’s and moderator’s interests or relationships that could influence the presentation with respect to interpretations, recommendations, and conclusions.

Please note: Unless listed below, faculty disclosure information was not provided

The following faculty have indicated that they do not have a significant financial interest:

Faculty Applicable Date Faculty Applicable Date Dr Steven Aung 10 Jun 2017 Dr Karen Madsen 10 Jun 2017

Dr Robert Bailey 10 Jun 2017 Dr Daniel Sadowski 10 Jun 2017

Dr Dawn Kingston 10 Jun 2017 Dr Jesse Siffledeen 10 Jun 2017

Dr Karen Kroeker 10 Jun 2017 Ms Dallis Westin 10 Jun 2017

Dr Allen Lim 10 Jun 2017 Ms Lisa Westin 10 Jun 2017

The following faculty have indicated that they do have a significant financial interest:

Nature and resolution of relevant financial relationship Faculty

Applicable Date

Commercial Interest What was received? For what role? Planned resolution

AbbVie, Celltrion, Ferring, Janssen, Shire, VSL#3 Honorarium Consultant / Advisory Board Member

AbbVie, Alba, Bristol Myers Squibb, Celltrion, Centocor, GSK, Genentec, Janssen, Merck, Millennium, Novartis, Pfizer, Proctor & Gamble, Roche, VSL#3

Clinical/Basic Research Grants

Investigator Dr Richard Fedorak

10 Jun 17

Metabolomic Technologies Inc. Equity Owner/Shareholder

Program Co-Chair (no presentation)

Aptalis Honorarium Advisory Board Dr Vivian Huang

10 Jun 17 AbbVie, Ferring, Janssen, Shire, Takeda Honorarium

Advisory Board, To fund this conference

Program Co-Chair. All talks generated by speakers and vetted by program

Allergan, Janssen, Lundbeck, Otsuka Honorarium Advisory Board Dr Glenda MacQueen

10 Jun 17 Pfizer

Honorarium Advisory Board, Research Committee

All talks generated by speakers and vetted by program

The following faculty have indicated that the content of their presentation will include discussion of investigative use or off-label application of medicines, medical devices, or procedures:

Faculty Applicable Date Faculty Applicable Date

The following faculty have indicated that the content of their presentation will not include discussion of investigative use or off-label application of medicines, medical devices, or procedures:

Faculty Applicable Date Faculty Applicable Date

Dr Steven Aung 10 Jun 2017 Dr Glenda MacQueen 10 Jun 2017

Dr Robert Bailey 10 Jun 2017 Dr Karen Madsen 10 Jun 2017

Dr Vivian Huang 10 Jun 2017 Dr Daniel Sadowski 10 Jun 2017

Dr Dawn Kingston 10 Jun 2017 Dr Jesse Siffledeen 10 Jun 2017

Dr Karen Kroeker 10 Jun 2017 Ms Lisa Westin 10 Jun 2017

Dr Allen Lim 10 Jun 2017 Ms Dallis Westin 10 Jun 2017

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