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Welcome back to the Joppa Podcast, where we explore how PAs contribute to healthcare and the practice of medicine. And don't forget, as you're listening in today, listeners can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's learning central@cma.aapa.org before we introduce our topic and guest today, I just wanted to mention that we have a bit of a celebration today. Today celebrates the recording of our 100th episode. I'd like to thank all those involved with the podcast, prior hosts for the podcast, the editing team, the JAPA editorial board, aapa, our guests, and of course our listeners. Without all of your support, this would not be possible. I especially want to thank my co host Kim and Martine for allowing me to be a part of the team and the JAPA Editor in Chief, Rick Dean, for his unwavering support. All right, so today we are diving into a really important topic published in the March edition of JAPA regarding ulcerative colitis. Here to guide us through an updated primary care approach to ulcerative colitis are the authors of the article, Sarah Bolander, Kim Carter, Tiffany Cook, and Nicole Hamilton. To start us off, if you could each just introduce yourselves and tell us a little bit about how you became interested in today's topic. Sarah, let's start with you.
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A
Thanks Joe. So I have been a PA for just shy one year, shy of 20 years. I've been in PA academia for about 12 years and currently work full time in the PA program at Northern Arizona University. And this project started when we recognized there was a gap in the literature. We we discussed that PAs in primary care are frequently managing patients with ulcerative colitis, yet they might not be fully aware of all the options available or the importance of going on beyond just simple symptom control. And so as we saw that the landscape was shifting with the expansion of biologics, small molecules and biosimilars, and that those were transforming how we approach treatment and making our management increasingly personalized, we felt like this was a project we wanted to take on. So I was really fortunate enough to collaborate with three incredible PAs who brought their GI expertise to the work, two who are registered dietitian, which allowed us to not only speak to some of the traditional management within gi, but the additional focuses on nutrition and non pharmacologics that aren't always discussed. So it was truly a collaborative effort and I couldn't have asked for a better team.
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B
Thanks Sarah Kim Thanks Joe.
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C
And I want to thank JAPA for the opportunity to join today. I have been a PA for 16 years and I have practiced both in internal medicine and gastroenterology previously at the University of Pennsylvania in Philadelphia in their outpatient GI department. So I transitioned into academia about a decade ago and so I joined Midwestern University PA Program in Glendale, Arizona and I currently serve as the Director of Clinical education. But my passion is in offering education and I really enjoy doing serving as faculty for CME programs on GI topics. This particular topic was of interest to me because of the landscape for UC and really the paradigm shift that we're seeing with a focus on mucosal healing now and not just clinical remission. So really a necessary topic for primary care providers. So I hope this is beneficial to listeners today.
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B
Great. Thanks Kim and Tiffany.
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D
Yeah, and I also am very happy to be here. So I have been a PA for 22 years and I was a dietitian before a PA school. So I'm one of the two dietitians. I'm still a dietitian. I joined full time academia about four years ago but I do still practice clinically and I've actually worked in inpatient GI for the last nine years. So I tend to see more of the kind of worst of ulcerative colitis its complications and I was really excited about the opportunity to contribute to this article because it kind of allows me to share some insights and some guidance that can help clinicians and in turn patients navigate ulcerative colitis from the perspective of prevention, early management, quality of life, which is kind of the opposite end of the spectrum of what I usually deal with.
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B
Great. Thanks Tiffany and Nicole, hi there.
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E
I am very happy to be here. Thanks for having me as well. I have been a PA for about eight years and I previously practiced in inpatient and outpatient gastroenterology and hepatology in Indianapolis as well as in Arizona. And with this why I wanted to participate today I have transitioned into academia so I teach now as an assistant professor at Midwestern University with alongside Kim and I really enjoy providing education to our students, providing education to our our PAs that are out there practicing. It's already been mentioned there are so many new updates with treatment options and I think it's exciting to provide this update so that primary care providers in particular are familiar with what they're going to be seeing with their patients that do have ulcerative colitis. So again thanks for having me today.
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B
Thank you all for being here, and I am looking forward to this today because I think we've got some great representation for a really important topic. So let's get to some of these questions. PAs are often on the front lines for diagnosing and treating patients with bowel disease. What are some of the most commonly missed early signs of ulcerative colitis? And how do you think PAS can distinguish it from things like ibs, infectious diarrhea, or even Crohn's disease early on?
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C
Joe I'm happy to field this question and it's an important one. Certainly the identification of of UC is really essential in primary care and certainly where patients first often present. And so early UC can be subtle or potentially misdiagnosed as ibs, irritable bowel syndrome, infectious diarrhea, or even potentially like postprandial food insensitivities, lactose and gluten intolerance. And so I think it's really important as primary care providers that we're taking a very good thorough history. So querying for constitutional symptoms, querying for gastrointestinal luminal symptoms, but also those extraintestinal symptoms that may be associated with inflammatory bowel disease. And this is in concert with also specifically inquiring about alarm features, red flag symptoms, and so unintentional weight loss, rectal bleeding, iron deficiency, anemia. These can really help distinguish inflammatory bowel disease from ulcerative colitis, from other conditions such as ibs, celiac disease. And also we're wanting to distinguish to and potentially identify for potential colorectal cancer. So those three things are important. The other thing too is when we think about infectious diarrhea, we want to make sure that we're inquiring about risk exposures that the patient may have things that could increase our pretest probability that this patient might have an infectious exposure. So travel history, antibiotic use, sick contacts, all of that is important and that can help support our refute our differential. I think it's important for providers to recognize that there are potentially some symptoms that may be minimized or normalized, so rectal bleeding and that potentially being attributed to hemorrhoids. And that being a concern for potential ulcerative colitis, patients may have fecal urgency or tenesmus, which may be attributed to postprandial food insensitivities. And so and then of course, extra intestinal symptoms, I think sometimes arthralgia, eye pain, rash, those things may be overlooked, but in concert with luminal symptoms really should be raising our clinical suspicion for inflammatory bowel disease. And so I think it's important that we're looking at all of that and then understanding the episodes that the patient has. If these are recurrent episodes, I start to think more about that relapsing, remitting nature of inflammatory bowel disease. And so I think, you know, all of that together raises our clinical suspicion and things that we should be on the lookout for.
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E
Thanks, Kim.
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D
You know, coming from the primary care
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perspective, when we're in really busy clinics
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D
and seeing a wide variety of patients,
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E
we like to get your take on a practical approach.
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D
What labs, stool studies and imaging are most useful and where does fecal calprotectin really fit in?
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C
Thanks, Kim. Yeah, so I'm happy to answer this one as well. I think it's important again that we're considering the symptomatology, laboratory and diagnostic investigation. And so certainly CBC is important. That allows us to really assess for if a patient has anemia or leukocytosis, which would point to potentially inflammatory bowel disease or even colorectal cancer compared to such IBs. A CMP is helpful certainly as a baseline of our renal and hepatic status and so helpful if we're considering starting medical therapy. We want to know the baseline, but also to assess for things like electrolyte abnormalities or potentially elevated liver enzymes which may be associated. There's association of inflammatory bowel disease, ulcerative colitis and primary sclerosing cholangitis. So we can recognize that potentially with those elevated liver enzymes. And then of course, in addition to cbc, cmp, a C reactive protein and fecal calprotectant. Now, although these are non specific markers for inflammation, they and in concert together really can increase our clinical suspicion for inflammatory bowel disease as opposed to ibs. And so in particular, this fecal cal protectant can raise our clinical suspicion for inflammation. But we also use this when we're in a patient who has inflammatory bowel disease and we're assessing their response to therapy, maybe it's helping us to, you know, predict flares and response. So that's really important. Stool studies for infectious diarrhea is important. Cross sectional imaging to assess for any potential complications. But ultimately colonoscopy is what's necessary and this is what allows us to identify the disease extent and the severity. So really it's a combination of symptomatology, laboratory and diagnostic investigation that we would utilize.
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E
Great overview. And at what point should a PA
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D
escalate either for an urgent GI referral or even hospitalization?
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E
That's a really good question. Thinking about when you want to send your patient to the hospital I think is easy to get at right off the get go. If we have a patient that has acute severe ulcerative colitis, so they're having more than six bowel movements on the daily, they're passing frank blood, they're passing significantly bloody stools, we really need to be saying they should be going to the hospital. And then they also likely have signs of systemic toxicity. That's part of the criteria for acute severe ulcerative colitis. So do they have evidence of anemia? Do they have evidence of tachycardia? Are they febrile? Is there elevated, Is there erythrocyte sedimentation rate elevated? Sorry, I flipped that around. And so these are important factors that we certainly are going to be considering and that's going to say, yep, that patient needs to go and be managed in the hospital. We need to get this under control in terms of if you would send a patient with severe disease to the hospital, really be thinking about those systemic symptoms and the severity of their flare because they are still having more than five bowel movements a day above their baseline, they are passing significant amount of blood in that stool and then two, they can have those systemic features. And so that's going to tell you, yes, you likely need to be sending, you definitely need to be sending them to the hospital, especially with those systemic features now mild to moderate. If they're flaring with mild to moderate, that's where an urgent GI referral is going to be very appropriate. We want to get them in, we want to get them seen so that we can escalate their therapy if that's needed, but also to identify is there something else that's underlying, is there an infectious process that could be contributing, are they even taking their medication so, so that we can really evaluate them more as well. So those would be the two, the different times that I would think about sending them to an urgent GI evaluation.
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D
And can I just kind of piggyback off that? I think the bottom line too is, is always from primary care standpoint, you're a little bit worried about sending an appropriate referral. And I think the bottom line or the short answer is really the time to refer is when you no longer feel comfortable managing that patient, when you're not getting the results that you expect, or there's something that you're that's just not clicking. So coming from the GI perspective, I would much rather the, the pa if they're not comfortable managing that patient, you know, send them to GI Let us kind of work with that. I think, you know, for hospitalization, it's probably a little bit easier when you say, okay, this is definitely a sick patient with all the criteria that Nicole mentioned. But I think if you're no longer comfortable managing that patient, that makes it an appropriate referral for gi.
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F
Thank you for that. Nicole, you described very well severity to know when to send to the hospital, and Tiffany described when to refer. This is very important. I think. I would think me in primary care, this is GI is really not my gist. I would refer all of them to you guys. So once we've made the diagnosis or strongly suspected, the next challenge is understanding the severity and goals. What are we trying to achieve with these patients at the point that we're seeing them? I guess. Can you walk us through how disease severity is classified and how that directly impacts management decisions?
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E
Absolutely. So there are different criteria that we can use. True Love Way is a great example of criteria to help us identify the severity of the disease. And really, when we're thinking about this, it takes into consideration the patient's stool frequency, the presence of blood in the stool, endoscopic findings, and then that systemic toxicity. So a lot about what I had just mentioned. But let's also think about breaking it down into mild, moderate, severe, and then acute severe a little bit, too. So when we have that mild disease, our patients are having one to two bowel movements above baseline. They have blood in the stool less than 50% of the time, and they have some erythema on their endoscopy, their colonoscopy with a decreased baccular pattern, but they're not having those systemic features. So that's something really important to keep in mind. That's a mild presentation, escalating. Thinking about more moderate disease presentation, we have three to four bowel movements above baseline. So we have more stool, we have more blood in the stool. At least 50% of the time, we're seeing blood in that stool. And then our endoscopic findings are going to change as well. So we have marketed erythema. We also have a decrease in that vascular pattern. The mucosa itself is a lot more friable. And we can get those erosions too with this. Again, we're not seeing those systemic features, so that's really important to keep in mind with the mild and moderate patterns. And then as mentioned, once we get across into that severe differentiation, we have at least five bowel movements above baseline. Our patient is passing blood in the stool alone at times, and on endoscopy we see ulceration, we get spontaneous bleeding as we're passing the scope. And then we have those systemic features. So bringing that back, that anemia, that tachycardia, that febrile patient with that elevated esr. And then last but not least, we, the real kicker is that acute, severe ulcerative colitis with again, more than six bowel movements a day, blood in the stool, and then we have significant ulceration on endoscopy, severe mucosal damage, and we have systemic features. Now with this, the goals in terms of management are to induce remission, to get them to a point where we can maintain remission. So this goes into how we identify our treatment for these patients. So with this, we think about induction and maintenance options and those are going to be our amino salicylates, our biologics and our small molecules. And just based on that severity, we can, we can identify what our options are. With this mild and moderate, we're looking more at our amino salicylates. And then when we're in that moderate to severe category, that's really where we're getting into our biologics and our small molecules. With this in mind, we can use induction if we're really wanting to get them under control. An induction option that is across the spectrum, mild to acute, severe, is with our corticosteroids, but we're not using this long term. It doesn't fall into that category for maintenance. And then lastly, our immunomodulators, they are not indicated for induction because they take time to work, but we can use them for maintenance in our moderate to severe ulcerative colitis. So that's really how that severity comes into play, how we utilize it and how it impacts our treatment and our management decisions that we ultimately will make for our patients.
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F
Great, thank you. That was very extensive examination of those steps. The article also talks about a shift toward a treat to target approach. What does that actually mean in practice? And how do tools like CRP and fecal caprotectin help guide that? And also, why does mucosal healing matter?
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A
Thank you so much for asking about this. I think this is one of the things we were very excited to highlight in this article. Treat to target moves us beyond just making sure our patients are feeling better for that symptomatic relief. In practice, it's working towards measurable targets over a specific amount of time. Our short term goals really are that symptom improvement. We want our patients to feel better. Of course we do. We want CRP to start to normalize that's what we'll see first. But what some clinicians and even some patients may not realize is that although the patient's feeling better, they still have active mucosal inflammation that we can't detect clinically. So that's where that fecal calprotectin really becomes valuable. It correlates more strongly with endoscopic remission than the CRP alone would. And so it is a meaningful early sign that healing is actually occurring. But it's the long term target of endoscopic healing that we really needed to highlight. Because if colonoscopy confirms that there is ongoing mucosal damage, then the patient remains at an elevated risk for four flares, hospitalizations, and eventually, over time, colorectal dysplasia and cancer. So, of course, feeling well is so important for our patients, but it's not sufficient. We really need to look at how we can go beyond that for our patients. And so what's exciting is where we are now is that the expanding treatment options give us so many more ways to achieve mucosal healing and not just focus on the symptom control alone.
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B
Great. Thank you so much for that, Sarah. You know, so with so many emerging therapies, it can really be overwhelming, especially for us that don't deal with this on a, on a daily basis. Can you give us a simple framework? I know that Nicole kind of went into some of this, maybe just kind of go over a little bit of that simple framework of choosing treatment based on severity and disease location.
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C
Joe, I'm happy to feel this. I think it's important. While it's overwhelming, it's really an exciting time to have all of these therapies available to patients for the purpose of really honoring that paradigm shift of achieving mucosal healing and endoscopic remission that Sarah spoke about. So that's really exciting for us, I would say, when we consider treatment options, when we consider the classes of medications, the immunosalicylates, corticosteroids, immunomodulators, biologic small molecules that Nicole highlighted. Really the treatment selection is based on that extent of mucosal involvement. Are we working, are we identifying patients with proctitis limited to the rectum? Are we concerned with patients who have left sided colitis, full pan colitis? That really plays a factor in what therapies we might choose, as well as the severity of the disease. The disease activities at mild, moderate, severe. So there's that piece of it, but then there's also the treatment characteristics itself. So considering the route of administration, injection versus oral medications, considering the side effects of those therapies, but also potential drug, drug interactions, patient comorbidities, cost and access. So we kind of have to look at that entire clinical picture and to add on to some of what Nicole mentioned about each specific class of medication. I would say the aminosalicylates are more so for mild to moderate disease. And what's nice about these is that there are oral and topical therapies available. So when you consider a patient who has more distal disease, so suppositories, enemas, maybe we add on an oral therapy. So that allows us to kind of titrate that therapy a little bit more. Yes. Immunomodulators, biologics, small molecules, more for moderate to severe disease. And then I would say lastly with corticosteroids. And Nicole really highlighted this nicely. You know, I think it's important that we understand that corticosteroids help induce remission in patients with acute, mild to severe disease, but they're not appropriate for, you know, long term maintenance. They're not really working to sort of halt the progression of the disease as, as we see with our immunomodulators and our biologics and small molecules. And so really when we have patients on corticostero steroids, we need to be thinking about a bridge strategy, an exit discontinuation strategy to really transition them to steroid sparing agents to maintain that remission. And that's certainly something that we look at when we're considering disease activity. If we have patients who are steroid dependent or steroid refractory, we need to start thinking about other agents to help kind of stabilize and allow that mucosal healing to occur. So that's kind of the approach that, that I think is helpful to take.
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B
That's really helpful, Kim. Thank you. And you know, you, you mentioned the steroids especially, because I think, I think a lot of us that, that's kind of our go to for those, for, especially in that severe moment of, oh, I know what to do, let's, let's get them on some steroids. You know, what are, what do you feel like are some of the biggest pitfalls that PA should avoid when we're talking about steroid use and when we should be thinking about, you know, you already kind of mentioned about transitioning them away, but like, are there some key points for us to really take away of? This is a, this is how we need to approach steroid use.
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E
Kim definitely hit on this already, but I think that it's important that we've mentioned this multiple times is we're not intending to use steroids in the long term for these patients. When we are looking to put our patients on steroids for induction, we need to be thinking about having that exit strategy. It should be in the back of our mind already. Where are they going with their management? Are they going to go to immunomodulators once they've been induced for maintenance? Are they actually needing to already be on biologics? So that's something that I would really strongly encourage us to all be thinking about because we think about the risk of chronic steroid use. So on top of their ulcerative colitis, we could be causing this patient to develop adrenal suppression, weight gain, hyperglycemia, osteoporosis. We can see cataracts, peptic ulcers. So I can't express how important it is to be really mindful of our chronicity with which we are using the steroids. They're a great medication and they work to reduce that inflammation rapidly in the acute setting. But we need to be planning to get them onto alternative therapy within three months.
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C
Truly, Jo, if I may add, too with that, you know, I think this really highlights the importance of interdisciplinary collaboration, right, in our patients, you know, being seen likely in the primary care setting in an acute flare, maybe they're started on a two month, one month prednisone taper and really ensuring that that patient is following up with their gastroenterologist. So there is some continuity of care there. And maybe we're needing to escalate therapy or change therapies to ensure that, you know, we're meeting our goal of endoscopic mucosal healing, making sure they're following up with colorectal cancer surveillance, all of that. So I think that really kind of highlights from a primary care perspective, if you're seeing a patient who's coming in multiple times with flares, ensuring that they're following up with gi. When was their last GI visit? I think that's really important y' all
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E
have mentioned, and I think it's very
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D
interesting that there are several therapies to
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E
consider outside of steroids.
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D
So those biologics and small molecules have really expanded options. How do you simplify choosing between them
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E
and what key safety screenings are essential before starting these medications?
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C
Thanks, Kim. Yeah. So, you know, I think it's important to remember that our therapy for ulcerative colitis is really dynamic and we have now available therapeutic drug monitoring which really allows us to optimize some of these medications, you know, between classes and within the classes of medications. And so when we consider biologic therapy, that's really targeting, you know, different molecules within that inflammatory cascade. And you know, certainly for patients with moderate to severe disease, we find that biologics can be quite helpful too in patients who have extra intestinal manifestations. So that's certainly something to consider. But you know, when we consider potential side effects of therapy, certainly with biologics and small molecules, patients can be at risk for bone marrow suppression, hepatotoxicity, reactivation of tuberculosis and hepatitis B. So some pre screening things to consider, certainly cbc, CMP for our patients, for biologics, tb, hepatitis B, hepatitis C, HIV serologies, those are all important to gather. And then when we transition into, you know, other therapies, you know, in particular the S1Pmodules, they, you know, because of the risk of cardiac conduction abnormalities associated with those, that's where you need to consider ekg, cardiac consult. So really, again, getting that multidisciplinary team involved is really important. And, and so these can be screens, pre screens that are done but by primary care, but, but also patients who were on biologics and performing those on a regular basis to ensure their continued use of those therapies is important.
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E
I just wanted to piggyback a little bit on that question too because I admit that there are so many options and we have choices just within those classes too, too like we have infliximab and adeline MAB as TNF antagonists. And so with that, some thoughts to also consider are yes, we can identify what class we want to use based on the patient's risk factors and the adverse effects. But then it comes down to also considering mode of administration. Some patients do not want to sit there for one to two hours to go through their infliximab infusion. So of them are going to prefer utilizing subcutaneous like adalimumab. And so that's something to really think about as well and to talk with your patients about. And then I also want to bring up pregnancy too, because that's a consideration. So when patients are thinking about how they want to proceed with management, what medications are going to be contraindicated in pregnancy, which ones are appropriate to continue with pregnancy. So really keeping in mind that life planning as well, it's not just what adverse effects are likely for this patient or what risk factors the patient already has, but also what works for their, their lifestyle too, if we can accommodate that.
- [28:54]
D
Well, I appreciate the honesty And Nicole's
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E
perfect lead in to our next question. So, you know, we talk a lot about the limitations of treatments based on
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D
access to care and access to therapeutics
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E
based on all of the factors that you've already mentioned.
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D
How do you feel biosimilars have changed access and affordability in your own experience?
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E
So biosimilars, these are near identical copies of our biologics. And we have options with Infliximab, Adalimumab and Ustekinumab for these medications. With this, there is substantial cost savings that can be had for the patient. And the benefit is they've demonstrated meaning no meaningful, no clinical meaningful differences in their safety and effectiveness. So that's important to point out to your patients because we're not giving them an inferior medication at a lower cost. We're giving them something that is FDA approved compared to that reference product so it's safe and effective for their use at a lower cost. And in practice this can truly benefit the patients, especially when there is limitations to what they have access to with insurance. And so that's something that, especially if I'm starting a patient on management for uc, then I may consider starting a bio similar if we're worried about the cost limitations for them. So those are, that's the big thing that I would say is it's certainly starting to get into practice and it's something to think about as we're initiating medications for these patients.
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F
Thank you, Nicole. I feel like this entrance coverage issue follows us in every disease state. So we, I can, we can all relate to that. So when patients present with flares, we know that treatment needs to be timely. What's your step by step approach to managing an ulcerative colitis flare in the outpatient setting and how do you monitor for response?
- [30:53]
E
So initially I start with their history and identify any risk factors factors. Also talk to the patient about have they been taking their medication consistently. Once they start feeling good, unfortunately it does happen that they'll stop taking their medication and it's not okay. But we acknowledge that it happens and there's going to be some education that comes with that. But so look at the patient, the whole patient, what they have in front of you and then talk to them about like have they been on any non steroidal anti inflammatories, have they been using any antibiotics recently? Thinking about other risk factors factors here as well, have they been traveling and then identify some labs that we can order to push this further. Okay, so let's look at getting a cbc, cmp A crp, our fecal calprotectin. And this is going to help us to identify do they have any evidence of anemia, leukocytosis, are there electrolyte abnormalities, do we have elevation in our CRP or our fecal calprotectin that's more consistent with flare? And then make sure that with this too we get stool study. So do they have evidence of C. Diff, have they been on antibiotics like we mentioned? And so could that be contributing traveling Salmonella, Shigella, E. Coli are all reasonable to consider because we have increased stool frequency, we have more blood in the stool, more abdominal pain. So what is going on? And that's our intent is to identify, is there something that's complicating their disease, stool state and making them flare more that we actually need to intervene and treat in addition to the overlying uc. So once we have that information back, it's really important too to take this into consideration with their most recent colonoscopy because we may need to repeat that to understand what does the mucosa actually look like. Do we have more severe disease at this point? Have we had progression? Do we need to change their medication? Do we need to add a medication to help them overcome this flare? And then circling back once we have this all in front of us, educating your patient on the medications that they're going to be using, the importance of consistency with taking their medicines on time and as directed, talking to them about risks associated with non steroidal anti inflammatories and future antibiotic use as well. So putting that all together so that ideally our patients don't have this recur is the objective. Great.
- [33:29]
F
So with that said, what complications do you worry about most during those flares and what are the clear signs that a patient needs hospitalization?
- [33:38]
D
So I'll jump on this one if you guys don't mind. So I think you know, in addition to what Nicole mentioned earlier about more than five bowel movements above baseline with frank blood or systemic symptoms as indications for hospitalizations from the, from when during acute flares. The things that I worry about most are things like toxic megacolon, bowel perfs, severe bleeding or hemorrhage, sepsis. So if, if a patient's exhibiting any evidence of those, those need to be managed inpatient. Those are, those are indications for hospitalization.
- [34:09]
B
Great. Thanks, Tiffany. So one of the important parts of this article is that how much it really emphasizes the primary care role beyond just medications. So what does comprehensive longitudinal care look like for patients with uc from Like PA perspective, including cancer screening, vaccinations and bone health.
- [34:28]
D
Well, we could do an hour on this alone, so I'll try, I'll try to be succinct. So obviously the comprehensive care part is, includes the management strategies that Kim and Nicole and the treat target that Sarah have already talked about. And really important to kind of keep communication with gastroenterology and any other discipline that are involved. And so from a primary care perspective, you know, PAs there are kind of the gatekeepers and it's really important to make sure that that communication is established and ongoing. I also think that there's a huge component to preventative care, ensuring that patients are up to date on their vaccinations. For our article, we used the vaccine recommendations that are mainly based off professional societies, so largely the American Gastroenterological association, but also AAFP and the Gastroenterology and Hepatology Foundation. And these recommendations differ slightly from what the CDC recommends and patients may notice that. So I think it's really important for PAs to consider all kind of the credible data and then share those sources with the patients. In addition to vaccines, you know, patients with UC are at increased risk for skin cancer, colorectal cancer, cervical cancers. Some patients may need screening colonoscopies as often as annually. And so not only do the PAS need to kind of be aware of the age appropriate and risk appropriate screening recommendations, but also helping patients understand why they're necessary, that no, you really can't skip the colonoscopy this year. And so being able to kind of communicate that effectively. And then bone health, we've kind of already talked about about that. Steroids aren't intended to be chronic, but we do have some patients that, that are on chronic corticosteroid therapy. We have some patients that have chronic malabsorption or at risk from a malnutrition standpoint. So at the very minimum, monitoring serum calcium and vitamin D levels in patients, if you suspect any deficiency or risk of malnutrition, supplementing those, those values as needed. And then any patient that's been on steroids for more than three months really should be getting a DEXA scan to, to evaluate their bone density.
- [36:26]
E
In addition to all that, mental health and quality of life are huge.
- [36:30]
D
So how should PAS proactively address anxiety and depression that patients with UC may experience along with the overall burden of disease? Thank you for asking this question and I'm going to jump in again before anyone else has a chance to say anything because I'm now I'm excited. So Obviously, you know, PAs can kind of proactively support mental health by just asking the questions. So screening routinely for anxiety and depression and normalizing mental health discussions. So letting patients know that psychological symptoms associated with chronic disease, including UC are common, they're somewhat to be expected and they're very treatable. Talking about to patients about coping strategies, integrating referrals to mental health professionals, talking, connecting patients with support groups or peer networks can maybe help patients feel less isolated. Every follow up visit, do a quick mental health check, especially if there's been a recent treatment change or an acute flare. That's when anxiety and depression tend to go up more in patients and then reinforcing how medication adherence and monitoring and follow up can actually reduce some of the anxiety and stress related to the disease. Unpredictability. Encouraging good wellness behaviors like exercise, sleep, hygiene, talking about stress reduction techniques, the importance of mindfulness. These are all things that can help patients understand their role in their disease and symptom control and disease progression and may actually help them gain a sense of control.
- [37:53]
A
I also just want to mention, I think this is a fantastic. I'm excited like Tiffany. So I think this is a great example of why UC requires a multidisciplinary team and how there's so many more support out there than you might be aware of. And this really hits to the goal of not just treating the disease, but treating the individual that's living with it. And so I think that just really, you know, hits that and why we were so excited to bring these additional aspects of treating patients with ulcerative colitis beyond just the updates to the medication management.
- [38:27]
F
Thank you for this. I must say this is the part of the article that I kind of liked the most and I was surprised about because I was not expecting this at all for uc. I mean when I was in school it's always UC Crohn's disease, how to differentiate them, how to treat. I mean I would never think about this holistic approach and you know, those behavioral wellness. I think about this for everything else, you know, cardiovascular disease and I never, I would never think that GI had that too, that you guys are cool like this. So Tiffany touched on it a little bit on those non pharmacological strategies like diet, exercise or complimentary therapies. So which one of those actually make a meaningful difference in your experience?
- [39:13]
D
Well, thank you for saying that first of all, because I think that was one of the things that I'm most proud of with this article is that we, in addition to covering kind of the paradigm Shift to treat to target and the new pharmacologic options. We do actually discuss kind of wellness behaviors and complementary therapies. And I think that was really unique too. So thank you for saying that. I think that the things that are important to remember are that diet obviously plays a huge role, but dietary therapy has to be individualized. And it's really important that patients understand that one dietary approach does not work for all patients. It's very individualized. And really every patient with UC should be routinely working with a registered dietitian. And I don't just say that because I am one. I just think it's so important and it's such an important component. And because as. As PAs in primary care, you just don't have enough time to get into the nuances of the dietary component. So it's really, really valuable. But I do think it should be done kind of separately just to be able to kind of delve into that. You know, we know that exercise helps, so we know that exercise helps with not only reduced disease activity, but it can help with bone health. It can improve quality of life. It's stress reduction. So I think exercise obviously is a big one. There's certainly a role for supplementation, especially if that's something that's important to the patient. Things like probiotics, things like curcumin have actually been shown to improve, to reduce inflammation, but little things like getting enough sleep, staying hydrated, those are really, really important. And those are things that patients don't have to go out of their way to do. And so super important to kind of get that baseline and then being able to explain to patients that acupuncture or cognitive behavioral therapy or mindfulness TR actually have the potential to improve quality of life. And so again, going back to kind of the shared decision making that Nicole has talked about, but understanding that there's a role for lots of different things and helping the patient kind of determine what's important to them and then being able to offer support in those areas is a really important, you know, that traditional medicine, like we talked about, that we learned about in PA school, is really. The non traditional medicine piece is really important as well.
- [41:25]
B
Thanks, Tiffany. All right, so now we're getting towards the end. I want to do some rapid fire questions, our little rapid fire round. All right, so tell us, what's one common myth about ulcerative colitis that you'd like to debunk?
- [41:40]
D
So Joe said rapid fire, and I immediately started sweating. I'm like, oh, no, no, no. There's pressure so since I've been talking so much these last few minutes, I'm just gonna keep going. This is why everyone wanted me to be quiet at the beginning. So I think myth, especially for providers to understand or clinicians to understand so they can help their patients understand. It used to kind of be that if you were diagnosed with ulcerative colitis, the question is, when are you getting your colectomy? When are you going to have your colon removed or some type of other worst case scenario outcome? And that's just not the case anymore. With new treatments, we're seeing better patient outcomes, we're seeing colectomy rates go down. And so really emphasizing with the patient that there's so much we can do now in comparison to maybe, you know, what was believed in the past.
- [42:26]
F
That's a good one.
- [42:28]
A
And I think one other is just that even if your patient feels better, that doesn't equate to ulcerative colitis is now under control. And so I think that lends really well into what Tiffany was saying. But symptomatic improvement doesn't equal that that mucosal lining is actually healing. And so even inflammation, even if it's silent inflammation, can still carry a real risk. And so we need to educate our patients as well as other clinicians that are treating patients with ulcerative colitis.
- [42:56]
B
That's great. Any other clinical pearl takeaway that you'd like our listeners to remember from the episode today?
- [43:02]
D
All right, one last thing. I'm going to say one last thing. You see, you got me spun up. You can't feel free. So I think, and we've really kind of touched about this, which thank you so much for giving us the opportunity to kind of explain this. But just remember that there's a whole patient there, there's, there's so much more that we have available to us now than we have in the past. And that one treatment option for one of your patients is going to be completely different for another one of your patients. There's no one size fits all. It's very nuanced. And ulcerative colitis can impact so many different facets of, of the patient's life that, you know, we have such great advancements in pharmacologic options. We're really not focused on symptomatic control anymore. We really want that treat to target approach. But there's also those effective, you know, non pharmacologic strategies. And this is where that shared decision making is so important. Helping patients feel like they have a say in their care, creating an environment where they feel safe to ask questions or discuss concerns, I just think is really, really important.
- [44:06]
A
And I think that's where that mental health component really plays in as well, is making sure we're not just asking the patients, we're concerned about how they're doing, but all patients, because really this is a quality of life issue as well that goes well beyond just, are we managing their symptoms?
- [44:23]
C
Yeah. And I think it really highlights the importance of, you know, UC really requiring this comprehensive multidisciplinary approach focusing on that early diagnosis, looking, assessing for potential subtle signs, treat to target, and those health maintenance measures. I think getting everyone involved is really important, paramount in the care.
- [44:44]
B
All right, so final question. What excites you the most about the future of UC management?
- [44:50]
C
I mean, I can certainly share. You know, for me, it's really been the treatment options that are available now really have allowed clinicians to really support the dual goal of not only clinical remission, but really focusing on that mucosal healing, endoscopic remission. And this is really for purposes of halting that disease activity, that disease progression, really preventing some of those potential complications. So, you know, I think that's a really important thing to highlight and recognize as the paradigm shift. And we have opportunities now to be able to do that with the options
- [45:26]
E
available to piggyback on that a little bit too, with those new management options. And we're going to see more, I just know it. We are seeing a time where patients that had different contraindications or failed management have more options. So they're not just stuck with a few medications. They have more of a choice in their management. And so that's also where we can actually start utilizing more shared decision making. They're not pigeonholed into a treatment just because they have this disease process. So. So it's really exciting and I know, I am thrilled to see what keeps coming down the pipeline in terms of disease management for uc.
- [46:10]
B
Yeah, thank you guys so much. I mean, this has been really helpful and I think, I think our listeners are going to get a lot out of this. I think the article was just excellent and I. I think it was such a great way to present practical information. And what a great update for us on the treatment and care of our patients with ulcerative colitis. So thank you very much and thank you all for joining us. And to our listeners, don't forget that the podcast is associated with cme. To receive your CME credit and access your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's Learning Central at CME aapa.org until next time. Thanks.