1 st draft IBS/IBD Cross CCG pathway - PowerPoint Presentation

Slide1

1st draft IBS/IBD Cross CCG pathway

This based on the guidelines written

Dr

Bu’Hayee

and NHS Greenwich CCG Medicines Management Team

Patient presenting with lower gastrointestinal symptoms for at least 6 months suggestive of irritable bowel syndrome (IBS) WITHOUT ALARM SYMPTOMS:

•

A

bdominal pain (relieved by defaecation, made worse by eating IBS-A)• Bloating (IBS-B)• Constipation (IBS-C) altered bowel frequency or stool form• Diarrhoea (IBS-D) is common; overlap exists (IBS-M– mixed)

Bloods normal and/or FCALP <60

FBC, ESR, Calprotectin

Coeliac screen, TFTs, (stool MCS)

Refer for ‘new IBD’ OPA via fax/hotline (to be seen <2-6/52)

Bloods normal and/or FCALP 60-150

Repeat FCALP in 4 weeks from first test; Consider IBS advice in meantime (with proviso of re-test)

IBS pathway 1: Presenting with symptoms, but unknown IBD

Primary care

Secondary care

IBS pathway

Suggest Advice &

Guidance for:-1. Equivocal FCALP results, these can be monitored over a longer period every 4-6w. 2. Patients with –Ve FOBT rarely require further investigations3. Patients with simple dyspepsia <55, that are non-responsive to ppI can be classified as IBS-A,

RED FLAGSUnintentional weight loss New IDAPersistent rectal bleeding/bloody diarrhoea that does no resolve.A family history of bowel or ovarian cancer > 60 years of age, a change in bowel habit lasting more than 6 weeks with looser and/more frequent stools

Consider 2WW/Urgent Referral to GI/Colo-rectal

Consider C+B referral, avoid advising dietary restrictions

Raised CRP, ESR and/or FCALP >150

+

Ve

Coeliac Screen

Increasing concern, struggling with

symptoms suggest refer on.

Trail

Ispaghula

and

Macrogol for 3/12 each

Bloating, pain, diarrhoeaIBS pathway 2:

Treatment options

Primary careSecondary care

All treatment options are based on recommendations of NICE CG61 IBS 2015.

Constipation predominant symptoms

Offer verbal and written lifestyle and physical activity advice, see next page.This only applies to patients that IBD or other significant pathology has been excluded via IBS initial algorithm

Key symptom

Mebeverine

135mg tablets 1-2 three times a day

Loperamide

2mg capsules 2-4 caps twice a day max 16 mg daily

Community dietics referral for FODMAPS

Referral to Gastroenterology for second line treatmentsPain/Diarrhoea based Constipation/Bloating

Amitriptyline 10mg-30mg at night Nortriptyline 2.5mg-10mg at night

Fluoxetine 20mg once daily

Citalopram 10mg to 20mg once daily

Encourage a frequent bowel habit, as this will help decrease symptoms

If pain and IBS-C consider

guanylate

cyclase

-C receptor agonist

Linaclotide

290 micrograms once daily for 6 weeks, can be initiated be Primary and Secondary

Dietary/Lifestyle Sheet

Have regular meals and take time to eat.

Avoid missing meals or leaving long gaps between eating.

Drink at least eight cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas. Restrict tea and coffee to three cups per day. Reduce intake of alcohol and fizzy drinks. It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice); REDUCE INSOLUBLE FIBRE. Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods. Limit fresh fruit to three portions per day (a portion should be approximately 80 g). People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products. People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day); INCREASE SOLUBLE FIBRE. Some people find taking probiotics regularly helps relieve the symptoms of IBS. However, there is no scientific evidence to prove that probiotics work and have beneficial health effects. If you decide to try probiotics, make sure you follow the manufacturer's instructions and recommendations regarding dosage, you should continue for at least 4 weeks to notice any difference. This is not available on prescription. Some people claim therapies such as acupuncture and reflexology can help people with IBS.

Coeliac

Pathway:

Primary care

Secondary care+

Ve Coeliac Screen, but not diagnosed

Not anaemic, raised LFTs, +VE TTG

High GGT, ALT

Offer direct access OGD

Organise C+B appt approx 4/52 post OGD date

See in clinic organise, explain diagnosis, organise DEXA and

dietics RV

Dietics; Stable weight and

dexa over 18/12

Stable in community, advise regular vaccinations, good compliance with GFD

Patient declines

Organize US

Check AST, plts, alb. Calculate NAAFLD Score at http://www.nafldscore.com

Score over -1.45Fatty Liver

Isolated GGT – reassure no further action

Organize C+B

appt

Maximise cardiovascular risk/diabetes lifestyle factors

Repeat LFTs every 24/12

Suggest Urgent to routine referral dependant on US findings

IBD pathway

1:

ULCERATIVE COLITIS

Mesalazine (5asa) pathwayPatient with known UC with flare of symptomsTaking mesalazine only

On maximum dose(4.8g Mesalmaine, 3g Salofalk,

4g Pentasa)

On zero or maintenance dose(2.4g Mesalamine, 1.5g Salofalk

, 2g Pentasa)On rectal 5asa therapy alone (enema or supps

)Severity of this flare?

MILDBO 1-3x per day +/- bloodNo systemic symptoms

MODERATEBO 4-6x per day with bloodNo systemic symptoms

SEVEREBO >6 per day with blood

Fever, tachycardia, hypotension

Call Gastro

SpR

on-callAdmit via Medical teamSeen by IBD Cons within 48hIncrease to maximum dose 5asa; Consider adding rectal therapy

Add oral 5asa at maximum dose and strength2/52 review if Rx changed. Symptoms controlled?

Continue maximal therapy for 4/52 then reduce to maintenance unless evidence of disease activity

Advice from IBD

helpine and/or refer for urgent OPA via helpline(<2/52)

≥ 2 flares in last 6/12?

YES

MAY NEED DISEASE-MODIFYING THERAPY

EG. AZATHIOPRINE

NO

Primary

or

secondary care

Secondary care

NO

YES

Patients with

Colonic Crohn’s

disease may be treated on this

pathway.

Consider

minimising tablet

burden with high strength

formulations if not

already

Newly

diagnosed patient

CONTACT SECONDARY CARE

AT ANY STAGE IN THIS PATHWAY

CHECK / ENCOURAGE ADHERENCE

- Typically 55% are adherent -

http://www.nice.org.uk/guidance/cg76/chapter/key-principles

Prescribe

prednisolone 40mg OD reducing by 5mg per week to zero with

Ca+vitD

suppl

OD

IBD pathway

2:

IMMUNOSUPPRESSANT

progression to BIOLOGIC THERAPYPatient requiring therapy despite pathway 2Start AZA based on TPMT result

High risk IBD?Steroid dependency

AZA monotherapy

Response

at 12 weeks?

Offer of shared care

NOVACCINATION AND VIRAL SCREENShould be performed at this stage

YES

NO

INITIAL AZA MONITORINGFortnightly FBC

for 3/12, then every 3/12 there after

TGN level at least at 12/52Recheck

if failing therapyResponse at 12 weeks?NOYES

Primary careSecondary careShared care can only start after 4/12 and only if patient stableINFLIXIMAB

Rescue, initial funding request for 12/12Hospitalised patient

In-hospital response?

“Acute severe”

UC

CI to biologic?

NO

?Surgery

Biologic

Pathway (

#3)

YES

YES

Remission for biologic cessation is defined as asymptomatic and biochemical and/or endoscopic and/or radiologic evidence of healing

NO

Alternative

immunomodulator

?

TACROLIMUS/MTX

Start point 1

Start point 2

High risk or Complex IBD

Young patients (<40 years); Fulminant disease

Previous surgery for Crohn’s disease / early recurrence

Fistulising/penetrating Crohn’s disease

at presentation

Unable to use steroids as bridge to immunosuppression

Already on immunosuppression (and adequate dosing)

Virtual / telephone/ nurse-led F2F follow-up

YES

IBD pathway

3:

BIOLOGIC

THERAPY, links for pathway IBD 2Secondary carePossible to dose-optimise based on drug/Ab level?UCCD

aTNF

Response at 12-16 weeks?

Switch biologic, and consider combinationNO

Dose optimisation or drug-switching must be discussed in IBD MDMReassessment may be

at 4-8 weeks after change, dependent on dosing frequencyThis cyclical section of the pathway can be repeated TWICE.

Suitable for clinical trial?

Remission at 12 months?

Possible to dose-optimise based on drug/Ab level?

NO

NO

Consider stopping

biologic therapyADALIMUMABINFLIXIMABVEDOLIZUMAB

Remission for biologic cessation is defined as asymptomatic and biochemical and/or endoscopic and/or radiologic evidence of healingThe most appropriate and cost-effective anti-TNF will be selected according to NICE guidance for CD

Expect 20% of local population of CD in this armThe proportion of patients will be higher in tertiary care (population outside LSLBGB)60%40%

2nd lineonly

These figures are for new starters only. Switching of stable patients is clinically inappropriate

On AZA? Need to optimize

YES

Anti -integrinYES

Remission for acute severe UC defined by

Mayo <2 when steroid-free

OPD should offered subcut anti-TNF or

Vedo as first line,Hospitalized IV

aTNFs.

NO

YES

NO

?Surgery