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[Guideline Summary] Medical management and monitoring of inflammatory bowel disease (IBD) in Asia

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In view of the increasing incidence and prevalence of inflammatory bowel disease (IBD) in Asian countries, the Asian Organization for Crohn’s and Colitis (AOCC) and the Asia Pacific Association of Gastroenterology have established recommendations on medical management of IBD specifically in Asia.

7 min read

Background:

  • IBD has become common in Asia over the past few decades with some areas experiencing a more rapid increase than in Western countries.
  • Differences in clinical manifestations and genetic risk factors are observed between the East and the West.
  • In consideration of the above, AOCC and the American College of Gastroenterology collaborated in the development of recommendations on medical management and monitoring for IBD in Asia.

Method:

  • A list of clinical practice recommendations was developed by an AOCC recommendation panel formed by 251 experts from 12 Asian countries and regions.
  • Voting on the recommendations was obtained from clinical practitioners and graded according to level of agreement (see below).
  • Among a total of 40 recommendation statements, 32 were approved and established whereas the remaining 8 were rejected as consensus was not reached.
     

Approved and established recommendations:

Pre-treatment evaluation

Differential diagnosis with intestinal tuberculosis

1. Intestinal tuberculosis should be excluded before IBD diagnosis, and patients should receive diagnostic anti-tuberculosis treatment when differential diagnosis is difficult.
[Strongly agree: 81.3%; Agree: 15.5%; Uncertain: 2.8%; Disagree: 0.4%]
 

Latent tuberculosis screening and chemoprophylaxis

2. IBD patients should be screened for tuberculosis by chest radiography and purified protein derivative (PPD) skin test or/and interferon gamma release assay (IGRA) before anti-TNF-α therapy.
[Strongly agree: 82.1%; Agree: 15.5%; Uncertain: 2.0%; Disagree: 0.4%]

3. IBD patients with latent tuberculosis infection should receive biological agents in combination with prophylactic anti-tuberculosis treatment with at least isoniazid during the first 6 months.
[Strongly agree: 64.3%; Agree: 31.3%; Uncertain: 2.8%; Disagree: 1.6%]
 

Screening for opportunistic infection

4. IBD patients should be screened for HBV, HCV, HIV and syphilis before corticosteroids, immunomodulators or biologics treatment.
[Strongly agree: 75.4%; Agree: 21.4%; Uncertain: 2.8%; Disagree: 0.4%]

5. All IBD patients with positive HBsAg, even with normal liver transaminases and negative HBVDNA, should receive antiviral therapy with Entecavir or Tenofovir at least 1 week before biologics application. Liver transaminases and HBV-DNA should be checked regularly.
[Strongly agree: 65.9%; Agree: 23.4%; Uncertain: 5.6%; Disagree: 5.1%]
 

Evaluation of perianal involvement

6. IBD patients should receive pelvic MRI or perianal ultrasound to exclude perianal disease before deciding treatment plans.
[Strongly agree: 48.0%; Agree: 37.3%; Uncertain: 13.1%; Disagree: 1.6%]
 

Medical management of active inflammatory bowel disease

Treatment strategy for inflammatory bowel disease

7. Step-up strategy should be recommended to induce remission in patients with mild to moderate ulcerative colitis (UC).
[Strongly agree: 76.0%; Agree: 22.0%; Uncertain: 2.0%; Disagree: 0%]
 

5-Aminosalicylic acid(5-ASA)/Sulfasalazine (SASP)

8. The use of 5-ASA/SASP should be recommended to induce remission in patients with mild to moderate ulcerative colitis.
[Strongly agree: 84.0%; Agree: 14.0%; Uncertain: 2.0%; Disagree: 0%]

9. The combination of oral and topical 5-ASA/SASP preparations should be recommended for proctitis, left-side colitis or pancolitis to induce remission in patients with mild to moderate ulcerative colitis.
[Strongly agree: 67.0%; Agree: 29.0%; Uncertain: 4.0%; Disagree: 0%]
 

Steroid

10. The use of corticosteroids should be recommendedto induce remission in patients with severe ulcerative colitis.
[Strongly agree: 76.6%; Agree: 21.8%; Uncertain: 1.6%; Disagree: 0%]

11. The maximum duration of intravenous corticosteroids use before switching to rescue therapy should be recommended as 5 days.
[Strongly agree: 35.3%; Agree: 51.2%; Uncertain: 9.9%; Disagree: 3.6%]
 

Immunosuppressive and biological agents

12. The use of anti-TNF-α agents should be recommended to induce remission in patients with moderate to severe Crohn’s disease (CD) and severe ulcerative colitis.
[Strongly agree: 46.0%; Agree: 46.0%; Uncertain: 7.5%; Disagree: 0.4%]

13. The use of anti-TNF-α agents monotherapy over thiopurine monotherapy should be recommended to induce remission in patients with moderate to severe CD and UC.
[Strongly agree: 48.0%; Agree: 38.5%; Uncertain: 10.3%; Disagree: 3.2%]

14. The use of anti-TNF-α agents in combination with thiopurines over anti-TNFα agents monotherapy should be recommended to induce remission in patients with moderate to severe Crohn’s disease when blood ATI increases and/or drug concentration decreases.
[Strongly agree: 61.1%; Agree: 32.9%; Uncertain: 5.2%; Disagree: 0.8%]
 

Treatments: Miscellaneous

15. We recommend nutrition support during the induction of remission in patients with CD.
[Strongly agree: 62.0%; Agree: 26.0%; Uncertain: 12.0%; Disagree: 0%]

16. IBD patients should routinely receive nutritional risk assessment and undertake nutritional support based on the result.
[Strongly agree: 69.4%; Agree: 24.6%; Uncertain: 6.0%; Disagree: 0%]

17. IBD patients should receive iron supplement if they have hypoferric anemia.
[Strongly agree: 69.4%; Agree: 27.0%; Uncertain: 3.6%; Disagree: 0%]

18. IBD patients should receive calcium and vitamin D3 supplements if they have osteoporosis.
[Strongly agree: 67.9%; Agree: 27.4%; Uncertain: 4.7%; Disagree: 0%]
 

Medical management of inflammatory bowel disease in remission

5--ASA/SASP

19. The use of 5-ASA/SASP should be recommended to maintain remission in patients with UC.
[Strongly agree: 82.0%; Agree: 15.0%; Uncertain: 15.0%; Disagree: 0%]

20. 5-ASA/SASP should be continued long-term in maintenance treatment.
[Strongly agree: 73.0%; Agree: 24.0%; Uncertain: 3.0%; Disagree: 0%]
 

Steroid

21. The use of corticosteroid should not be recommended for maintenance of remission.
[Strongly agree: 71.0%; Agree: 9.0%; Uncertain: 5.0%; Disagree: 15%]
 

Immunosuppressants

22. We recommend using thiopurines over no immunomodulator therapy to maintain remission in patients with CD.
[Strongly agree: 52.0%; Agree: 40.0%; Uncertain: 7.0%; Disagree: 1.0%]
 

Management of inflammatory bowel disease during the periconception period and pregnancy:

23. Female IBD patients should cease methotrexate for at least 3 months while thalidomide should be completely prohibited before conception.
[Strongly agree: 82.0%; Agree: 14.0%; Uncertain: 3.0%; Disagree: 1.0%]

24. Female IBD patients could be treated with corticosteroids or biologics only under the full consideration of the pros and cons during gestation.
[Strongly agree: 61.0%; Agree: 34.0%; Uncertain: 5.0%; Disagree: 0%]

25. Female IBD patients could use biological agents till 22–24 weeks of gestation to minimize fetal exposure.
[Strongly agree: 47.0%; Agree: 40.0%; Uncertain: 11.0%; Disagree: 2.0%]

26. Female IBD patients should take 2 mg/d folic acid supplement daily to prevent neural tube deformity if they receive SASP treatment at least 3 months before conception or during pregnancy.
[Strongly agree: 53.0%; Agree: 34.0%; Uncertain: 12.0%; Disagree: 1.0%]
 

Surveillance strategies for colitis-associated cancer:

27. UC patients, or CD patients with colon involvement should routinely receive endoscopy with multiple biopsies from multiple segments starting from the 8th year after diagnosis.
[Strongly agree: 52.4%; Agree: 34.9%; Uncertain: 11.5%; Disagree: 1.2%]

28. UC patients with low grade dysplasia in flat mucosae should reexamine endoscopy in 3–6 months and receive pancolectomy when necessary.
[Strongly agree: 58.7%; Agree: 32.5%; Uncertain: 6.4%; Disagree: 2.4%]
 

Monitoring adverse events of thiopurines and methotrexate

29. IBD patients should routinely receive Full Blood Count, liver, renal and pancreatic function tests during thiopurine or methotrexate treatment.
[Strongly agree: 70.6%; Agree: 24.6%; Uncertain: 4.8%; Disagree: 0%]
 

Infections in inflammatory bowel disease:

30. Clostridium difficile should be tested for in IBD patients who have recurrence or aggravation of diarrhea during treatment.
[Strongly agree: 85.3%; Agree: 12.7%; Uncertain: 2.0%; Disagree: 0%]

31. CMV should be tested for in IBD patients with colon involvement if their conditions steadily deteriorate during treatment.
[Strongly agree: 82.1%; Agree: 15.5%; Uncertain: 1.6%; Disagree: 0.8%]

32. Acute severe UC patients should be routinely tested for Clostridium difficile and CMV.
[Strongly agree: 77.0%; Agree: 18.6%; Uncertain: 3.6%; Disagree: 0.8%]
 

Link to publication:
https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/33317546/
 

WYE-EM-047-MAR-21

Reference

Ran Z et al. Asian Organization for Crohn’s and Colitis and Asia Pacific Association of Gastroenterology practice recommendation for medical management and monitoring of inflammatory bowel disease in Asia. JGH. 2021;36:637-645.
 

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