COMMENTARY

The New Gastroenterology Data That Primary Care Teams Need to Know

World Congress of Gastroenterology (WCOG) at the American College of Gastroenterology (ACG) 2017 Annual Scientific Meeting

David A. Johnson, MD

Disclosures

January 02, 2018

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

Welcome back to another installment of GI Common Concerns.

In this discussion, I want to highlight for my primary care colleagues some of the important messages that came out of the joint meeting of the American College of Gastroenterology (ACG) and the World Congress of Gastroenterology (WCOG), recently held in Orlando, Florida.

When I come back from such meetings, I provide an overview for gastroenterologists, but I often wish that my primary care colleagues would know about these things too, because they may be even more applicable to their practices. This meeting produced several highlights that are particularly noteworthy. The primary care team should really be aware of these now and not have to wait until they are ultimately published in journals.

Acute Pancreatitis

The first study of interest was a single-blind, randomized controlled trial of hospitalized patients with acute pancreatitis that assessed the best time to reinstitute oral feedings.[1] The traditional training that you've likely received is to make these patients NPO. However, this study was actually quite provocative and supportive of others that have concluded that early refeeding is actually helpful, in terms of improved time to oral refeeding as well as reduced pancreatitis severity.

This is quite a paradigm shift in that patients can come in as soon as they're able (eg, not experiencing vomiting or abdominal distention) to initiate oral feedings. This strategy promotes gut integrity, which is what we really want to see in pancreatitis patients, and also has the benefit of earlier oral feedings resulting in patients leaving the hospital sooner. The study didn't show a difference in the length of stay, but again, the oral refeeding times and reductions in pancreatitis scores were quite significant. On the basis of these and other results, I believe that early oral refeeding is something to consider.

Alcohol and Bariatric Surgery

The second study of interest[2] assessed the characteristics of patients referred for bariatric surgery. Most of the time, gastroenterologists don't get involved in this, but you and your surgeons perhaps will be affected more by these results. This study reported that new-onset, increased moderate- to high-risk alcohol consumption occurred in more than 8% of patients following bariatric surgery. Approximately 20% of patients reported an overall problem with drinking prior to surgery.

Why is there an uptick in alcohol abuse following bariatric surgery?

One of the things we have often seen in my practice is that following a successful bariatric surgery, people experience new self-esteem. They have body habitus changes, and they may become disenchanted with the life they previously lived and with their spouse or partner. These feelings may lead to increased alcohol use. This is something that you as a primary care team should be aware of and monitor for going forward.

Thiopurine and Skin Cancer

The next study[3] looked at the use of thiopurines, which we in gastroenterology use to some degree for autoimmune diseases and inflammatory bowel disease. They are also used a lot for rheumatologic diseases. Thiopurines have been associated with non-melanoma skin cancer (NMSC).

Using a Veterans Affairs Health Care System database, the authors found that approximately 3% of patients on thiopurines had NMSC. What was particularly noteworthy was that 98% of patients who were diagnosed with NMSC continued to receive thiopurines. Approximately 50% of patients experienced at least one recurrence of NMSC within a year or two, and approximately 50% had two or more recurrences in that same timeframe.

I now have any patient who is receiving a thiopurine see a dermatologist at least annually for monitoring, and I recommend that you as a primary care team do so as well.

Fresh Frozen Plasma and Cirrhosis

The routine use of fresh frozen plasma is now recognized to have no value in patients with cirrhosis and gastrointestinal (GI) bleeding.

Baxi and colleagues[4] looked at the timing and number of units of fresh frozen plasma used in this setting to determine whether it improved patients' GI bleeding status; the answer was no.

If you are the primary care or ER team trying to resuscitate patients presenting with GI bleeding, you'll find that the use of fresh frozen plasma really doesn't do much good. In fact, it may actually do harm. It would require 20-40 mL/kg of fresh frozen plasma to normalize vitamin K–dependent deficiency in a patient with portal hypertension. This may actually increase their portal hypertension and predispose them to ongoing bleed.

Additionally, many patients with cirrhosis are hypercoagulable and have decreases in protein C, so we now routinely minimize, or eliminate altogether, fresh frozen plasma, which is a recommendation I extend to the patient's primary care physician as well.

Currently, I look at a patient's fibrinogen level, and if it's quite low (<100 mg/dL), I will then consider adding cryoprecipitate.

Again, fresh frozen plasma should not be a first response when you see a coagulopathy associated with cirrhosis.

Ondansetron's QT-Prolonging Potential

Another interesting analysis[5] looked at patients receiving ondansetron (Zofran), a medication with QT prolongation potential.

Researchers analyzed 9000-plus episodes of ondansetron co-prescribed with another QT-prolonging medication in over 2700 patients. This is considered to be a major interaction, yet in almost all of these cases (85%) they were overridden by the prescriber because they were not identified as being significant.

The most common classes of these co-prescribed QT abnormality medications were macrolide antibiotics (40%), fluoroquinolone antibiotics (17%), serotonin antagonist and reuptake inhibitor antidepressants (13%), and selective serotonin reuptake inhibitor antidepressants (10%). Remember that anti-arrhythmics can have this effect as well, and approximately 2% of co-prescriptions were amiodarone and flecainide.

The important point is to recognize that these are not potentially inconsequential abnormalities. The most common QT-prolongation co-prescription medications in this study were azithromycin, levofloxacin, and trazodone. Be on the lookout for these in your patients taking ondansetron. Don't just dismiss it and override it. QT drug interaction is a real deal and a potential problem.

Cannabinoid Hyperemesis

The final study of interest[6] came from researchers in Texas who, over the past decade, analyzed patients presenting with nausea and vomiting. They reported an increase in patients they believed to have cannabinoid hyperemesis.

This is something that you will potentially see in your practice if patients are being prescribed cannabinoids, which may be helpful in treating protracted nausea. However, cannabinoid use on a regular basis may paradoxically increase nausea and vomiting. As cannabinoids are now available not only via prescription but are legally for sale in several states, we may see a rising potential for cannabinoid hyperemesis. So if you're seeing a patient with nausea and vomiting, ask about cannabinoid use. This may be an important clue when you gather their appropriate history.

In conclusion, there are lots of points for primary care teams to consider. Hopefully, they will be on your mind when you encounter patients relevant to these findings and will be a useful guide in your interactions with them.

I'm Dr David Johnson. Thanks again for listening. We'll see you next time.

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