Day 5 and beyond – Discharge planning
Patients who have responded to the initial intravenous steroid course by hospital day 5 should have successfully transitioned to oral steroids with plans to start an appropriate steroid-sparing therapy shortly after discharge. Treatment planning should commence prior to discharge and should be communicated with the outpatient GI team to ensure a smooth transition to the ambulatory care setting, primarily to begin insurance authorizations as soon as possible. If the patient has had a meaningful response to infliximab rescue therapy (improvement by more than 50% in bowel frequency, amount of blood, abdominal pain), discharge planning needs to prioritize obtaining authorization for the second dose within 2 weeks of the initial infusion. These patients are high risk for readmission, and close outpatient follow-up by the ambulatory GI care team is necessary to help direct the tapering of steroids and monitor response to treatment.
If the patient has not responded to intravenous steroid therapy, infliximab, or cyclosporine by day 5-7, then surgery should be strongly considered. Delaying surgery may worsen outcomes as patients become more malnourished, anemic, and continue to receive intravenous steroids. Additional preoperative optimization may be required depending on the patient’s course up to this point (Table 2).
Summary
The cornerstones of inpatient UC management center on a thorough initial evaluation including imaging and endoscopy as appropriate, establishment of baseline parameters, and daily assessment of response to therapy through a combination of patient-reported outcomes and biomarkers of inflammation. With this strategy in mind, practitioners and care teams can manage these complex patients using a consistent strategy focusing on multidisciplinary, evidence-based care.
References
1. Truelove SC et al. Br Med J. 1955 Oct 23;2(4947):1041-8.
2. Ho GT et al. Aliment Pharmacol Ther. 2004 May 15;19(10):1079-87.
3. Tinsley A et al. Scand J Gastroenterol. 2015;50(9):1103-9.
4. Issa M et al. Clin Gastroenterol Hepatol. 2007 Mar;5(3):345-51.
5. Ananthakrishnan AN et al. Gut. 2008 Feb;57(2):205-10.
6. Negron ME et al. Am J Gastroenterol. 2016 May;111(5):691-704.
7. Taylor KN et al. Gynecol Oncol. 2017 Feb;144(2):428-37.
8. Rubin DT et al. Am J Gastroenterol. 2019 Mar;114(3):384-413.
9. Jalan KN et al. Gastroenterology. 1969 Jul;57(1):68-82.
10. Gan SI et al. Am J Gastroenterol. 2003 Nov;98(11):2363-71.
11. Makkar R et al. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):573-83.
12. Hindryckx P et al. Nat Rev Gastroenterol Hepatol. 2016 Nov;13(11):654-64.
13. Yerushalmy-Feler A et al. Curr Infect Dis Rep. 2019 Feb 15;21(2):5.
14. Shukla T et al. J Clin Gastroenterol. 2017 May/Jun;51(5):394-401.
15. McCurdy JD et al. Clin Gastroenterol Hepatol. 2015 Jan;13(1):131-7; quiz e7.
16. Cottone M et al. Am J Gastroenterol. 2001 Mar;96(3):773-5.
17. Nguyen GC et al. Gastroenterology. 2014 Mar;146(3):835-48 e6.
18. Limsrivilai J et al. Clin Gastroenterol Hepatol. 2017 Mar;15(3):385-92 e2.
19. Targownik LE et al. Am J Gastroenterol. 2014 Oct;109(10):1613-20.
20. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.
21. Travis SP et al. Gut. 1996 Jun;38(6):905-10.
22. Syal G et al. Mo1891 - Gastroenterology. 2018;154:S841.
23. Ungar B et al. Aliment Pharmacol Ther. 2016 Jun;43(12):1293-9.
24. Laharie D et al. Lancet 2012 Dec 1;380(9857):1909-15.
Dr. Chiplunker is an advanced inflammatory bowel disease fellow; Dr. Ha is associate professor of medicine at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center, Los Angeles.
