The Young and The Restless: Managing the Adolescent with Inflammatory Bowel Disease - PowerPoint PPT Presentation

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The Young and The Restless: Managing the Adolescent with Inflammatory Bowel Disease

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Perspectives on Pediatric Natural History: What Are We Measuring? ... ideal weight for height. Effect of Daily Corticosteroid Therapy on Growth in Children With IBD ... – PowerPoint PPT presentation

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Title: The Young and The Restless: Managing the Adolescent with Inflammatory Bowel Disease


1
The Young and The Restless Managing the
Adolescent with Inflammatory Bowel Disease
  • Marla Dubinsky, MD
  • Cedars-Sinai Medical Center
  • David Geffen School of Medicine, UCLA

2
Natural History of Crohns Disease
  • In both adults and children, the disorder is
    characterized by periods of variable clinical
    activity
  • Pediatric CD often more severe at presentation
  • Evaluation of natural history in children
    involves more than disease activity (eg, growth,
    QOL)
  • Biological behavior (phenotype) and genetic
    background affect course and response to therapy
  • All Crohns disease is not alike Crohns
    diseases

3
Perspectives on Pediatric Natural History What
Are We Measuring?
  • Clinician Patients in remission
    With mucosal healing Patients needing
    surgery Patients in hospital With serious
    adverse events
  • Child/Adolescent Can I go to school? Can I
    play with my friends? Do I look like everyone
    else? Will I grow? Can I date? Will I
    die?

4
Cumulative Incidence of Surgery From the Time of
Diagnosis in Pediatric Patients (1979-2003)
Years Incidence 95 CI1 5.7 4.3
7.45 17.0 14.1 20.4 10 28.4 22.5 35.6
of Patients
Years Since Diagnosis
Gupta N, et al. Gastroenterology. 20061301069.
5
Immediate and Long-Term Outcomes of
Corticosteroid Therapy in Pediatric CD
No Response 17
Complete Response 60
Partial Response 24
Surgery 8
Steroid- Dependent 31
Prolonged Response 61
N109
Markowitz J et al. Clin Gastroenterol Hepatol.
2006Jul 21 Epub.
6
Evaluation of Agents in Changing the Natural
History of Crohns Disease
  • Induction of remission
  • Maintenance of remission
  • Prevention of disease progression to penetration,
    stenosis (heals mucosa)
  • Prevent post-op recurrence
  • Improve quality of life
  • Facilitate normal growth and development
  • Benefitrisk ratio

7
Crossed 2 percentiles
Diagnosis
No weight gain or change in height for 3 years
8
Patterns of Growth Failure In CD
A Decrease in height velocity before onset of
symptoms of CD (median 12 months) B Decrease in
height velocity after onset of symptoms but
before diagnosis C Normal height velocity up to
diagnosis
Kanof M, Gastroenterol 198895
9
Growth Failure - IBD
  • Poor weight gain/short stature
  • Crohn disease gt ulcerative colitis
  • 15-40 prevalence
  • May be presenting symptom
  • May be irreversible

10
Assessment of Short Stature in the Pediatric IBD
Patient
Height

Low Wt/Ht

Ht
Delayed
lt 3

velocity

Bone Age

lt 3

IBD









Related






0
Endocrine







Constitutional Delay

0
0








0
0


Genetic



ideal weight for height
11
Effect of Daily Corticosteroid Therapy on Growth
in Children With IBD
No Prednisone Daily Prednisone
0.650.22
0.440.25
Growth Velocity (cm/mo)

0.230.26

0.030.07
Mild Disease
Moderate/Severe Disease
n 73 12 10 31
Plt0.001
Hyams JS et al. J Pediatr. 1988112893.
12
Kaplan-Meier Survival Curve of Relapse-Free
Duration of Remission
6-MP Controls
1.00
0.75
0.50
Fraction in Remission
0.25
0.00
0
100
200
300
400
500
600
Days From Start of Remission
Plt0.007Markowitz J, et al. Gastroenterol.
2000119895-902.
13
6-MP and Growth
  • 55 children with active Crohn disease
  • Mean age 13 2 y
  • Prednisone 6-MP
  • At 18 months in the 6-MP group
  • Steroid sparing effect
  • Prolongation of remission
  • Same linear growth!

Markowitz J et al. Gastroenterology
2000119895-902
14
Duration of Response Following Initial Infliximab
Infusion Early vs Late CD
Early CD (n 6)
100
Late CD (n 8)
75
Patients Without Relapse ()
50
25
0
0
8
16
24
32
40
56
64
48
Weeks Following Infliximab Infusion
Kugathasan S et al. Am J Gastroenterol.
2000953189.
15
Pediatric Infliximab REACH Study Design through
Week 54
All subjects
Visits

Week 0
Infliximab 5 mg/kg

Week 2 Week 6

Responders
NonrespondersNo further infliximab
Week 10
Infliximab 5 mg/kg q 8 weeks
Infliximab 5 mg/kg q 12 weeks
Week 14


Week 18

Week 22


Week 30
Week 30

Week 38

Week 42

Week 46
Evaluation at Week 54
Infusions
Hyams et al. NASPGHAN 2005 poster.
16
REACH
Clinical Response at Week 10
Proportion of Subjects ()
17
Clinical Remission at Week 10
REACH
Proportion of Subjects ()
18
REACH
Subjects in Clinical Remission
p0.013
plt0.001
Proportion of Subjects ()
19
REACH
Height Velocity Z-score
20
Enteral Nutrition vs. Corticosteroids in Active
CD A Meta-Analysis
Log Odds Ratio (95 CI)
0.1 0.3 0.5 1 2 4 10
Study Year Lochs 1991Malchow 1984Gonzalez-Huix 1
993Gorard 1993Lindor 1992OMorain 1980Seidman
1993Seidman 1991
Pooled odds ratio
Corticosteroids Liquid DietMore Effective More
Effective
Reproduced with permission from Griffiths AM et
al. Gastroenterology. 19951081056.
21
Effect of Intermittent NG Tube Feeding on Growth
in Crohns Disease

plt 0.01
Belli D et al. Gastroenterology. 1988 94603-610.
22
Surgery and Growth
  • Well timed-surgery for refractory
    disease/obstruction enhances growth
  • Alperstein G et al. J Pediatr Surg 198520129-33
  • Lipson AB et al. Eur J Pediatr. 1990149687-90
  • McLain BI et al. Arch Dis Child. 1990
    Jul65(7)760-.

23
(No Transcript)
24
Pediatric Bone Adult Bone!
www.keithryan.com/Images/strongbaby.jpg
25
IBD and Bone
  • Effects of the disease are unique in the skeleton
    of children
  • Adults Direct effects on bone
  • Children Growth arrest direct effects
  • Pathogenesis likely a gut bone axis
  • But evidence is circumstantial

26
DEXA Pediatric IBD
  • Beware of the pitfalls of DXA in children
  • Always use Z-score, never T-score
  • A Z-score lt -2 low bone mineral density for
    age, not osteoporosis
  • A low Z score by itself should not be a reason to
    start anti-resorptive treatment

27
Management of Bone Health in Pediatric IBD
  • Osteopenia common in CD gt UC
  • Bone density consider QCT
  • Interpretation according to bone age or height
    age (due to delayed maturation)
  • Therapy Vit D Ca supplements, bisphosphonates

Herzog D et al. Inflamm Bowel Dis 1998 4 261-7
28
Psychosocial Issues in Following Pediatric IBD
Patients
  • Interferes with physical activity
  • Limits social interactions/self-esteem
  • Disrupts education
  • Impairs growth
  • Delays sexual maturation/puberty
  • Impacts upon therapeutic success

CONCLUSIONS Although mortality is low, IBD is a
major lifelong challenge to the psychosocial
resources and functioning of the child and family
29
Behavioral/Emotional Functioning
  • 25-30 of children with IBD have symptoms of
    depression and/or anxiety.
  • 10-30 meet criteria for clinical depression or
    an anxiety disorder.
  • These rates are similar to children with other
    chronic illnesses (similar to healthy control
    adolescents in some studies).

Mackner L, Crandall W, Szigethy E. Inflamm Bowel
Dis. 2006 Mar12(3)239-244.
30
Behavioral/Emotional Functioning
  • Predictors of depression
  • stressful life events
  • maternal depression
  • family dysfunction
  • steroid treatment
  • older age
  • /- disease severity

Mackner L, Crandall W, Szigethy E. Inflamm Bowel
Dis. 2006 Mar12(3)239-244.
31
Eating Problems
  • Children with IBD have significantly more
    problematic eating behaviors than healthy
    children.
  • Gender differences in predictors
  • For girls, body image was a sig. predictor of
    eating problems but weight was not.
  • For boys, weight was a sig. predictor but body
    image was not.

Mackner L, Crandall W, Szigethy E. Inflamm Bowel
Dis. 2006 Mar12(3)239-244.
32
Medication Adherence in Pediatric CD
53 patients (age 14.2)
58 prescribed both
REFILL RATES dependent on ? being off
prednisone ? refill of other concomitant
medication ? younger patient
33
Children Are Not Just Little People The
Perspective Of Adherence
  • Expect setbacks
  • Adherence can be improved by collaboration
  • Expect probabilities not certainties
  • Focus on factors that promote/disrupt
  • Flexible treatment prescriptions
  • Recognize improvement not perfection

34
Pediatric Versus Adult Healthcare
Pediatric Care
Adult Care
  • family-centered
  • multidisciplinary
  • parent primary caregiver and decision-maker
  • may ignore growing independence and increasingly
    adult behavior
  • patient-centered
  • single physician
  • acknowledges patient autonomy and independence
  • may neglect family concerns

35
Barriers to successful transition in IBD
Perspective of Pediatric Institution
PEDIATRIC HEALTH CARE TEAM
PARENTS
inadequate understanding of importance of
transitional process limited resources for
implementation of a transition program
limited appreciation of adulthood with IBD
lack of familiarity with adult IBD programs
institutional policies re transfer
overprotection longstanding
relationship with pediatric team
36
NASGHAN Guidelines on Transition in
IBDRecommendations for Physicians
  • Seeing adolescent patients without their parents
    to build a relationship that promotes
    independence and self-reliance
  • Discussing with the patient and family benefits
    of transition to an internal medicine
    gastroenterology practice
  • Developing a relationship with an adult
    gastroenterologist who is knowledgeable in caring
    for young adults with a history of
    childhood-onset IBD
  • Providing all of the necessary medical records
    and summaries so that the family will realize
    that all providers are working together to
    deliver excellent care

NASPGHAN Guidelines on Transition in IBD JPGN
200234245-248.
37
Helping Young Patients Cope With IBD
  • Control disease, manage growth problem
  • Educate patient and family
  • Identify school and social problems
  • Identify compliance issues
  • Treat patient age appropriately be frank,
    consistent, honest
  • Psychosocial counseling
  • Support groups
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