Managing inflammatory bowel disease flares in primary care

Dr Kevin Barrett provides advice on managing patients with uncomplicated inflammatory bowel disease (IBD) experiencing flares - and highlights a new resource that could help GPs.

(Photo: Krisanapong Detraphiphat/Getty Images)
(Photo: Krisanapong Detraphiphat/Getty Images)

Crohn’s disease and ulcerative colitis, the two main forms of inflammatory bowel disease (IBD), are lifelong inflammatory diseases that affect the gut and extraintestinal sites such as the joints, skin, liver and eyes.

They affect up to 1 in 210 people in the UK1 and can be diagnosed at any age, although half of patients are diagnosed before early adulthood. IBD usually follows a relapsing-remitting course, with periods of disease remission, when the symptoms are largely under control, and flares, when significant and often debilitating symptoms occur.

Flare symptoms

Symptoms of a flare include urgent and frequent diarrhoea, sometimes with blood and mucus; fatigue; weight loss; and anaemia. The morbidity from flares is high, and the mortality can be as high as 3% due to sepsis and acute kidney injury.1

Around 50% of patients experience at least one relapse a year,1 which can have a huge impact on physical wellbeing, self-esteem and social functioning. It costs the NHS two to three times more to treat patients in a flare compared to those in remission.2

The RCGP and Crohn’s & Colitis UK IBD Spotlight Project was launched in 2017,3 to increase awareness of Crohn’s disease and ulcerative colitis and provide advice on carrying out initial investigations and referring patients appropriately to secondary care. The project is now focusing on flare management and supporting GPs to manage the disease in the long-term.

Managing flares

GPs are often the first port of call for patients having a suspected flare, yet 52% are less than confident or not confident in managing flares according to a Spotlight Project survey of 525 GPs and GP trainees carried out in April 2017.

To address this, a project group of patients, GPs, IBD clinical nurse specialists and gastroenterologists was established to co-create pathways based on NICE, BNF, and European Crohn’s and Colitis Organisation (ECCO) guidance. These new pathways have been endorsed by the British Society for Gastroenterology, the Primary Care Society for Gastroenterology and the RCGP.

Both pathways are available to view or download here: www.rcgp.org.uk/ibd.

New UK IBD Standards aim to bridge the gap between primary and secondary care. They recommend that patients should have an individualised care plan, including guidance on managing flares and details of how to access an IBD clinical nurse specialist.4

However, access to IBD advice lines run by nurse specialists can be limited in parts of the UK, and many patients do not yet have a care plan. Therefore, the flare pathways can assist GPs in supporting patients with established, uncomplicated IBD.

The pathways provide guidance for assessment of flare severity using established criteria, warnings when patients may be becoming septic (patients with IBD, particularly those taking disease modifying drugs, are at increased risk5), when to seek input from secondary care, investigations to carry out in primary care, initial medication changes or escalation, when to assess response to treatment, and when to revert to the baseline medication regime again.

Steroids have a place in the management of flares, but they must be used at an appropriate dose for an appropriate length of time. Overuse of steroids is common and carries with it increased risks of surgical complications and increased mortality.6 

Referral and treatment

Top tips for managing flares that are covered in the IBD Spotlight Project Toolkit include:7

  1. Confirm a flare is happening using blood inflammatory markers (CRP or ESR) or faecal calprotectin, but don’t delay starting treatment unless symptoms are mild.
  2. Discuss flare management with your IBD team unless they have issued a clear care plan for that patient. Inform them that a flare has occurred.
  3. Refer an acutely ill patient to the on-call medical team (significant fever, tachycardia, hypotension or anaemia).
  4. Use alternatives to oral steroids where possible – oral or rectal mesalazine or rectal steroids are the first-line treatment in UC. Increase the oral mesalazine dose to 4.8g/day if needed.
  5. Use oral steroids in CD, or UC not responding to mesalazines: start with 40mg/day prednisolone tapering by 5mg/week for 8 weeks = 252 x 5mg tablets in total.
  6. Consider budesonide 9mg/day for eight weeks as an alternative to prednisolone for mild to moderate ileal or ileo-caecal CD (ECCO guidance recommends an additional 4 weeks at 6mg/day).
  7. Don’t overprescribe – patients can stockpile steroids and use them to self-treat rather than seek medical attention and have flares documented.
  8. Assess response to treatment after two weeks or sooner if clinical deterioration occurs.
  9. Discuss escalating the IBD therapy with your local IBD team if a patient requires more than two courses of steroids in 12 months, they can’t reduce the dose below the equivalent of 15mg prednisolone/day or a relapse occurs within six weeks of stopping steroids.
  10. Remember bone protection when using oral steroids – co-prescribe calcium + D3, and consider a bisphosphonate if the patient is >65 or has established osteopenia or osteoporosis but beware the risks of bisphosphonates including gastric irritation and osteonecrosis of the jaw
  11. In Crohn’s disease, enteral nutrition is often the therapy of choice in children and can be used to induce remission in adults.

Wider impacts of IBD

Many patients with IBD receive all the support they need from their IBD teams, but GPs need to be aware of the wider impact of IBD.

Oral contraception may be less reliable in women with IBD who have malabsorption due to severe small bowel disease or resection, or who have vomiting or severe diarrhoea for more than 24 hours, and is therefore UKMEC Category 2.8

Patients on immunosuppressive therapy – for example, adults and children on corticosteroids (>20mg prednisolone per day or 1mg/kg/day in children under 20kg) for more than 14 days or adults on non-biological oral immune modulating drugs (such as methotrexate >25mg per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day) – should not receive live vaccinations (e.g. Fluenz Tetra, shingles or yellow fever).9 Therefore documentation of drugs issued by hospital teams should be documented in the GP prescribing record. The 2019 IBD Standards requires that changes to relevant medication is communicated to primary care within 48 hours.

The IBD Spotlight Project Toolkit

In addition to flare management, the IBD Spotlight Project Toolkit provides advice on diagnosis, nutrition, anaemia, fatigue, fertility, immunisations, and contraception for patients with IBD, and signposts to organisations including Crohns & Colitis UK and CICRA for detailed information on all aspects of the disease and support and resources for healthcare professionals and patients.  

The Spotlight Project Regional Champions3 are available throughout the UK to promote the Flare Pathways and provide educational sessions on diagnosis, flare management and supporting patients. Please contact kevin.barrett@nhs.net if you would like to find out more.

References

  1. Molodecky, NA, Soon, IS, Rabi, DM et al. Increasing incidence and prevalence of inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012; 142: 46-54.
  2. Ghosh N, Premchand PA. UK cost of care model for inflammatory bowel disease. Frontline Gastroenterology 2015; 6: 169-74.
  3. More information on the RCGP IBD Spotlight project is available here: https://www.rcgp.org.uk/clinical-and-research/our-programmes/clinical-priorities/spotlight-projects-2019-to-2020/inflammatory-bowel-disease.aspx
  4. IBD UK. IBD Standards. Available at: https://ibduk.org/ibd-standards
  5. NICE. Sepsis: recognition, diagnosis and early management. NG51, September 2017. Section on risk factors accessible here: https://www.nice.org.uk/guidance/NG51/chapter/recommendations#risk-factors-for-sepsis
  6. Barrett K, Saxena S, Pollok R. Using corticosteroids appropriately in inflammatory bowel disease: a guide for primary care. Br J Gen Prac 2018; 68: 497-8.
  7. RCGP and Crohn's & Colitis UK. Inflammatory Bowel Disease Toolkit. Available at: https://www.rcgp.org.uk/ibd
  8. Faculty of Sexual and Reproductive Health. Clinical guideline: SRH for individuals with inflammatory bowel disease. October 2016. Available at: https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-srh-ibd/
  9. The Green Book. Chapter 6: Contraindications and special considerations. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pdf

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