COMMENTARY

8 Key Primary Care Takeaways: Digestive Disease Week 2016

David A. Johnson, MD

Disclosures

June 27, 2016

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Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

I'm back from Digestive Disease Week (DDW) 2016, one of the national meetings for gastroenterologists. One of the nice things that comes from this meeting is information that is very applicable to primary care providers. Rather than wait for the articles to be published, I wanted to give you my snapshot view of how this new information may affect your practice and give you some perspective on what to look out for in the future.

More Data on the Low-FODMAP Diet

While there were a number of very exciting presentations, an important one focused on the fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) diet. This diet is used in irritable bowel syndrome (IBS) and is something that continues to be very effective from a gastroenterologist perspective.

This study was a randomized controlled trial from the University of Michigan that looked at a low-FODMAP diet versus a control diet based on modified National Institute for Health and Care Excellence (NICE) guidelines, both administered by dieticians, among participants with diarrhea-predominant IBS.[1] What they found was that the low-FODMAP diet made a tremendous difference in regard to the symptom-based composite endpoint used in this trial and in quality of life.

If you're treating these patients with IBS on your own, you should be paying attention to this FODMAP diet. The diet includes low amounts of fermentable types of carbohydrates, which the colonic and distal small bowel actually can ferment, causing a lot of different pain and sensory symptoms. Getting a dietitian involved can make a big difference, especially if these patients aren't seeing a gastroenterologist and are managed in primary care; however, gastroenterologists should also be involving a dietitian to counsel their patients.

This same research group actually took evaluation of the low-FODMAP diet a step further. They looked at the effect of the low-FODMAP diet on visceral nociception by changing the gut microbiome.[2] It makes sense that if you have this fermentable sugar going into the gut where there is potential for fermentation by bacteria, there may be changes in that gut bacteria, such as selective upregulation of some bacteria and downregulation of others. They actually showed that there are changes in the gut bacteria, which reflected changes in intestinal permeability.

This idea of IBS being just in a patient's head is not true, and it clearly needs to be thought of as somewhat of a potentially infectious disease, at least in a sizable composite of patients. We can do better with dietary treatment.

Partner Burden in Celiac Disease

One of the areas that I think primary care has a better role of understanding is in the partner burden of disease.

One of the interesting abstracts that was presented from a group at Columbia University in New York looked at the care burden for the spouse or partner of whomever had sustained illness.[3] They looked at 94 patient-partner pairs, with the patients having celiac disease. They found that there was a sizeable percentage of partners who had had really poor quality of life and poor sexual satisfaction.

Something that I think we need to do a better job of is looking at the impact of disease on family life and diseases that partners or spouses may have. Partner burden certainly increases the likelihood that these people without the disease may be having ongoing problems.

Caffeine and Risk for Fibrosis in Chronic Liver Disease

Another study that was interesting and is certainly something to emphasize to patients looked at the effect of caffeine on the ability to diminish the risk for fibrosis in chronic liver disease.[4] This systematic review and meta-analysis found that caffeinated beverages decreased the risk for progression of fibrosis in patients with hepatitis C.

The reason I brought this up is that it is something that we can have a strong conversation about in virtually all patients with chronic liver disease. For example, for patients with nonalcoholic fatty liver disease (NAFLD), I think it is a very viable opportunity to say that this is something they can do. We often emphasize weight reduction, diabetes control, and lipid control, but we can emphasize the benefits of caffeine consumption (eg, three or more cups of brewed coffee a day). Nothing else seems to have this sustained and sizeable effect on decreasing fibrotic activity in the liver.

Certainly this is something that I feel good about, because more often than not, we tell patients to stop doing things that they enjoy. For caffeine, if they like coffee, they should go for it.

Yoga for Ulcerative Colitis

There was an interesting trial on yoga and its effects on ulcerative colitis (UC).[5] In this study, they looked at the programmatic evaluation in 77 patients, and they found that there was a significant benefit in overall quality of life with yoga.

Yoga includes a variety of deep-breathing exercises and relaxation techniques. They didn't look at the effect on sleep in these patients, but we should start to talk about alternative or holistic treatments with patients who have UC. This is something that had an effect in a disease that obviously has a very complex pathogenesis, so yoga may be a new advent for UC. It could also be a good advent for a variety of other inflammatory diseases that we treat. This may be something to incorporate, at least in some of your daily discussions.

Colorectal Cancer Outcomes Associated With Delayed Colonoscopy

The traditional Hemoccult® (fecal occult blood test) has gone by the wayside for colorectal cancer screening. The current standard in the national guidelines is the fecal immunochemical test (FIT), which is based on very well-established evidence.[6]

A group from Kaiser Permanente in San Francisco looked at delay in colonoscopy after a positive FIT and its association with colorectal cancer–related outcomes.[7] This is something important to monitor in your practice. They found that patients who had a delay of 6-12 months had greater odds of colorectal cancer, including advanced-stage cancer, compared with patients who got a colonoscopy within 30 days after a positive FIT. A FIT needs to be pursued in a timely fashion, and a patient with a positive FIT needs to be referred to a gastroenterologist for a colonoscopy.

This study emphasizes the importance of programmatic follow-up by primary care providers to make sure that these patients are complying and following up and that they had a colonoscopy done in a timely manner.

Age Differences and Racial Disparities in Colorectal Cancer Epidemiology

As we've pushed for more colon cancer screening, we've seen somewhat of a decreased trend in colon cancer prevalence. Interestingly, we've seen an increasing trend for cancer in younger people.

There was a very nice study that looked at the National Cancer Data Base, and they found that over the course of the past decade, there was a 2.5% decrease in colorectal cancer cases among adults aged 50 years and older, where we had a new standard for colon screening in the absence of family history, but there was an increase of 11.4% in colorectal cancer in the less-than-50-year-olds.[8] They also found that there was somewhat of a racial disparity here, particularly with African Americans. To follow that, there was another study that looked at colorectal cancer using the Surveillance, Epidemiology, and End Results (SEER) cancer registry.[9] They found a striking increase in colorectal cancer incidence and later-stage cancer over the past decade among African Americans compared with other racial groups. It's important to recognize that the American College of Gastroenterology changed the national guideline recommendation in 2009, suggesting that African Americans be screened starting at age 45 years.[6] The American College of Physicians has endorsed this and actually suggests it even earlier.[10]

As you start to look at your patients, don't diminish any signs or symptoms in patients who are relatively young, thinking that they couldn't have colon cancer, because the answer is, they can. In particular, you should be pushing screening recommendations among African Americans, consistent with guideline recommendations that they should be screened earlier, beginning at age 45 years. Once they are screened adequately and a good-quality colonoscopy is done, these patients can be followed more on a standard interval. But, again, they need to start to be screened at age 45 years or sooner, based on signs and symptoms.

Refractory Symptoms and Proton Pump Inhibitor Dosing

Something else that caught my eye was on the issue of proton pump inhibitors (PPIs) in patients with refractory symptoms. Often patients are taking a PPI, but nonetheless they still have ongoing symptoms.

In this particular trial, they said, "Timeout—we are going to talk to patients about when to take their medication."[11] They gave patients about a 90-second talk about when to take their PPI (ie, 30-60 minutes before breakfast). The entry criterion was three or more heartburn episodes per week while taking a PPI (in this case, omeprazole). Patients were randomized to receive either the pep talk or just continue their ongoing therapy and were observed for several weeks. There was a highly statistically significant difference in gastroesophageal symptom resolution from just a brief intervention to promote optimal PPI adherence.

When patients come in and say they're not responding to a PPI, the first question should be about taking their medication—how and when are they taking it?

Sleep Fragmentation and the Gut Microbiome

The last study that I wanted to bring to your attention was a very fascinating study looking at the effects of sleep fragmentation on the gut microbiome.[12] You can't pick up a journal of any sort, primary care or specialty, and not see something about the gut microbiome.

This particular study looked at the effects of sleep on the gut microbiome and potential effects on immune function. This was a mouse study where they fragmented the sleep of mice and they looked at the microbiome, comparing with a control population of mice without sleep fragmentation. What is very interesting is that there is actually a circadian rhythm in the gut. In the course of the normal day, there is undulation, but a return to baseline from the day before. When they fragmented the sleep of these mice, they actually inverted this rhythm. Instead of a nice undulating clock-like mechanism, they found profound dysbiosis. We know that sleep fragmentation changes gut permeability, but we also can say that the gut is the largest immune system. They also looked at the mesenteric lymph nodes and their gene arrays that encode for the integrity of the gut wall—so, cytokines and chemokines that upregulate the integrity of the gut wall. These gene arrays were all inhibited. There was a major reduction in their viability, and they were basically downregulated.

Certainly when talking about immune function, we need to remember to talk to patients about sleep function. This is really a big wakeup call for us, as it starts to relate to gut dysbiosis and when patients are not responding to treatment. We need to take a good sleep history and talk to the patient about how they sleep and how they feel the next day when they get up. Sleep function is going to be really important as we start to tie this with the role of dysbiosis of the gut microbiome in virtually all diseases.

I wanted to give you a 30,000-foot view of the data that I thought were newsworthy from DDW 2016. You'll see more on these topics as the articles start to appear in in the literature, but I wanted to give you these updates that will hopefully steer you well in your next patient interactions.

I'm Dr David Johnson. Thanks again for listening.

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