COMMENTARY

Cutting-Edge Primary Care Data From Digestive Disease Week 2018

David A. Johnson, MD

Disclosures

July 25, 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 GI Common Concerns.

I've just returned from Digestive Disease Week (DDW) 2018, the national and international meeting for gastroenterologists that was held in Washington, DC, this year. I always return from this meeting and provide a specific review for gastroenterologists. However, lately I've also been doing this for primary care clinicians, giving them the cutting-edge information they need to know about in their general day-to-day activities. Here are my top five [from this year's meeting].

Screening Younger Patients for Colon Cancer

The first such study is about colon cancer screening and onset in younger adults.

Before we get into the data, it's important to know the backdrop for this. The US Multi-Society Task Force on Colorectal Cancer[1] has long recommended that African Americans be screened for colon cancer beginning at [age] 45. The American Cancer Society (ACS) came out, just before this meeting, with a new recommendation[2] to begin screening at [age] 45 for all Americans.

The new study presented at DDW[3] looked at a national data registry of nearly 2500 cases, which were then matched to case controls at approximately a 4:1 ratio, to see if colon cancer patients could have been detected had they been adequately screened. The ACS recommends that screening should be initiated at age 40 for those people who have one or more first-degree relatives or two or more second-degree relatives with colorectal cancer, or 10 years prior to youngest age of a first-degree relative with colorectal cancer.[4] The US Multi-Society Task Force recommends the same, with the exception of second-degree relatives, which was dropped from the most recent iteration of the guideline.[1] Researchers reported that the ACS screening criteria were only met by 25% of the patients who had colon cancer, meaning that 75% of those with colon cancer were not screened adequately.

An interesting pattern was also very evident in this study. The proportion of colon cancers relative to the onset of the first-degree relative was within a range of 34%-55%. In cancers developing in relatively younger patients, 44% were diagnosed almost at the same age as their first-degree relative.

As primary care physicians, we need to ask about family history and look at the latest recommendations relating to appropriate screening. Don't dismiss your primary care patients if you think they're too young to have colon cancer. Recognize that 10% of these cancers are now seen in those under the age of 50. GI bleeding is a discriminate here. But remember that we're not doing a very good job in identifying those that should be screened based on family history.

Diabetes Risks Elevated in Acute Pancreatitis

The second study[5] dealt with the issue of diabetes, which occurs more often in patients following an episode of acute pancreatitis—a very common diagnosis in our hospital systems, which we see over 250,000 times a year.

In studying how pancreatitis might predispose to the development of diabetes, researchers from university hospitals in Cleveland, Ohio, looked at a national data registry of people with acute pancreatitis. They excluded patients with chronic pancreatitis, diabetes, and pancreatic cancer. Lo and behold, they found that 22% of patients who developed acute pancreatitis were diabetic within 5 years, half of whom were on insulin. At the end of the first year, 12% of those had developed diabetes and 90% had been diagnosed within the first 6 months.

Confounding variables like hypertension, dyslipidemia, and obesity did increase the likelihood for diabetes. And in a very strange observation, the association with smoking, alcohol, and older age appear to be protective, which I don't really get.

The teaching point here is to monitor your patients following acute pancreatitis once you get them back in your practice and look for diabetes, given the very high incidence rates seen here. These are patients who need to be monitored and very likely will need to be on insulin.

Gallstones Symptomatic at Higher-Than-Expected Rates

The third study[6] dealt with asymptomatic gallstones.

We image for a lot of different reasons these days, and as we image more, we see more. With asymptomatic gallstones, the teaching has been that 1% a year will develop symptoms, and if they develop symptoms, 4% a year will develop complications.

This study from the Cleveland Clinic looked at the largest available database of patients with asymptomatic gallstones. They excluded patients who had any symptoms or any reason to undergo an ultrasound for gallbladder-related symptoms. Using natural-language algorithms and diagnostic codes, they identified approximately 19,000 adults (median age at diagnosis, 63 years).

After a median follow-up period of 8.1 years, the incidence of symptoms or development of problems was higher than what I've seen in the past, which makes this an important study for consideration. The annual incidence of right upper quadrant was 1.9%, pancreato-biliary events was 1.5%, and cholecystitis was 0.33%. The annual rate of experiencing any event was 5.1%, which is higher than what I've quoted my patients.

Going forward, it's important to reassure them that only a minority of patients will develop symptoms; but if they do, they need to look at cholecystectomy.

Oral Nutritional Supplementation Reduces Rehospitalization

The fourth study[7] was about the use of oral nutritional supplementation in malnourished patients.

This is something to be aware of if you're working in hospitals or inheriting these patients back in your practice from the hospitalist, because malnutrition affects up to 55% of hospitalized patients and can clearly contribute to adverse outcomes.

This is a very interesting retrospective cohort study from Johns Hopkins, in which researchers looked at a cohort of 8710 malnourished patients. Malnourishment was defined as screening positive for unplanned weight loss of over 10 pounds in the past 3 months prior to hospitalization, or reported decreased oral intake for 5 days prior to hospitalization. They looked at the rate of readmission after discharge and the variable of dieticians prescribing oral nutritional supplementation because they recognized it was of value.

Overall, there were 10.4% fewer readmissions for all diagnoses for those people who had this aggressive emphasis on nutritional supplementation. Interestingly, for oncology patients, the number was 21.9%. Patients in the intensive care group had a 51.3% reduction in 30-day hospitalization.

The takeaway is to think about oral supplementation. If you inherit them back, get on top of this. If you are a hospitalist, be on it right up front. Your hospitals will love you, because decreasing hospitalization is incredibly important.

Keeping Patients on Anti-Tumor Necrosis Factor (TNF) Agents

The fifth and final finding comes from two separate studies. Both report on the use of anti-TNF agents, which we employ in our world of gastroenterology for inflammatory bowel disease (IBD), Crohn disease, and ulcerative colitis, but they are also used for a host of other rheumatologic and dermatologic diseases.

The first study[8] looked at breastfeeding, specifically the lactation association risk for the infant and whether these drugs are transferred via breast milk. Researchers looked at an ongoing national data registry that monitors breast milk concentration to assess for the presence of the biologics infliximab, atezolizumab, certolizumab, natalizumab, ustekinumab, and golimumab. They looked at these over the course of breast milk secretion and found that there was no significant demonstrable breast milk transmission. Then they looked at the growth outcomes at the 1-year mark, reporting that there was no difference compared with the normal findings that you would expect in that time period.

In breastfeeding mothers, you are going to see more and more emphasis that we should be allowing them to stay on these agents, as there is basically no risk to the fetus and the infant, going out to the 1-year mark, compared with not being on these agents.

The other study[9] on the use of anti-TNF related to joint replacement. A lot of the time we get pushback from surgeons who ask us to stop these agents prior to surgery, even though they are quite formidable in preventing relapse of inflammatory, rheumatologic, or dermatologic disease.

This retrospective case-control study also used a national claims database—in this case, to identify nearly 1500 patients with IBD who had knee, hip, or shoulder replacement. Researchers looked at the outcome as it relates to infection risk in these patients going forward. They found that the 90-day reinfection risk profile was no different from if they had not been on these agents. A lot of the infection data that we were concerned about comes from abdominal surgery, where there would be a more formative infection risk.

I think you are going to see more and more emphasis with patients on the surgical track to allow them to continue anti-TNF agents going into common operations in order to maintain disease remission. As we get older, our joints get worse [and may need] replacement.

Keep in mind these two anti-TNF modifications as they relate to breastfeeding and joint replacement, as well as all five hot topics from DDW that impact my primary care colleagues.

I hope these are helpful and meaningful in your next discussions with patients.

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

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