#MondayNightIBD

A big thanks to #MondayNightIBD🏘️ for sharing their expertise in #VEOIBD 🌟#Back2Basics by @DLeVine901 🌟Convo led by @GutMD_ ✅ 💎#IBDAlgo by @AimenKhanMD 👇🏽👇🏽 & test your knowledge with the post- convo polls 🆓CME👉🏽 mnibd.short.gy/25-26

@MondayNightIBD @DLeVine901 @GutMD_ #IBDAlgorithm 🧬VEO-IBD 💭Think monogenic disease, esp. 🦠Recurrent infections 🍑Severe perianal Dx. 🚩 Growth failure 🧪 Genetic testing guides precision therapy & identify HSCT candidates early. 🎯 Diagnose first, then treat. 🗳️PostConvo polls👇(Answers in #IBDAlgo😉)

@MondayNightIBD @DLeVine901 @GutMD_ @JKurowskiMD @BenjamminGold @DrRosenIBD @ericbenchimol @dziring @DrMikeDolinger @NASPGHAN @DrChrisMoran @PedsGIChat @JenniferLeeLee1 #MondayNightIBD
#PostConvo #IBDPoll 1️⃣
🆓#CME👉🏼mnibd.short.gy/RehmanPost

What is true regarding the use of infliximab (IFX) in kids with VEO-IBD (answer in #IBDAlgo ☝🏽)

🔑BSA=body surface area dosing
🔑mg/kg= weight based dosing

@MondayNightIBD @DLeVine901 @GutMD_ @JKurowskiMD @BenjamminGold @DrRosenIBD @ericbenchimol @dziring @DrMikeDolinger @NASPGHAN @DrChrisMoran @PedsGIChat @JenniferLeeLee1 #MondayNightIBD
#PostConvo #IBDPoll 2️⃣
🆓#CME👉🏼mnibd.short.gy/RehmanPost

👦🏻pancolitis➕perianal dx at age 5. h/o liver abscess & dermatitis, limited reaponse to IFX
🕵🏽‍♀️You suspect chronic granulomatous disease (CGD)
🧪What is the next test you order?
🔑DHR =Dihydrorhodamine

@MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma 16 yo boy, Crohn's colitis + perianal fistulas at age3, growth failure;  Poor response to ADAL, now on IFX, still needs courses of prednisone. TL 10, no ATI H/o recurrent staph skin abscesses (axilla, perianal ), Aspergillus pneumonia  What would you do next?

@GutMD_ @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma Fascinating @GutMD_ Thinking immunodeficiency dis w opportunistic infection, although can be due to IFX; learned from @DLeVine901 🌟#Back2Basics that perianal dis in the very young is 🚩 for a potentially monogenic dis. ☎️the way smarter #PedsGI for help! @pdxIBD @BenjamminGold

@DCharabaty @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI Great clinical thinking!🎯 You're absolutely right to 🚩 immunodef over IFX-relatd opportunistic infection. Key distinction ➡️ patient's recurrent staph abscesses + aspergillus tht started in early childhood, suggest an intrinsic phagocyte defect vs iatrogenic immunosuppression.

@GutMD_ @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI Beside getting a more formal dx of the IBD type, any role for enteral nutrition here as induction of remission & improve nutrition status ? What would you do next?@nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu

@DCharabaty @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI @nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu 🧵 Great pivot @DCharabaty! EN absolutely has a role here but with a critical nuance 👇 1/4 1️⃣ For growth failure alone, EN is non-negotiable. Chronic inflammation + steroid exposure = linear growth suppression. Supplemental enteral nutrition can improve growth velocity #PedsIBD

@DCharabaty @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI @nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu 2️⃣ EEN as induction: strong 📊in pediatric luminal CD. Swaminath et al meta analysis showed EEN=steroids for remission. BUT isolated colonic CD shows reduced response to EEN (52% vs 68% remission, OR 2.74 for non-response (Xu et al.Clin Nutr 2019)

@DCharabaty @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI @nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu 3️⃣ ⚠️ 🚩The elephant: if this is CGD related colitis, EEN data is essentially absent. The inflammatory mechanism is NADPH oxidase-driven, not dietary antigen-mediated. 3/4

@DCharabaty @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @JKurowskiMD @DrChrisMoran @pedsgidoctora @GIJax_pedGI @nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu Nutritional rehab? Absolutely 💯. EEN as primary disease therapy? Unlikely to move the needle. There IS a case report of 2 infants achieving remission w EEN (Miller et al,Dig Dis 2017) but monogenic etiology wasn't characterized. Dx first, then tailor. 🧬 4/4 #MondayNightIBD

@GutMD_ @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma So sorry I am late to this discussion! I agree with the assessments above. When you have a patient with #VEOIBD, I would take a comprehensive approach including immunology and genetics evaluations.

@GutMD_ @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma In addition, there are different way of approaching nutritional therapy. EEN can be utilized for induction therapy and also utilized when considering adjunctive therapies in specific scenarios including patients who are pre-op for surgery.

@SCKimIBDMD @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma 💯 !! Comprehensive immunology and genetic workup is crucial to appropriate diagnosis. B2B 🌟 @DLeVine901 ⬇️

@GutMD_ @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma Nutritional optimization is a critical part in a multifaceted approach for Crohn’s, depending on the patient: therapy, nutritional optimization.

@GutMD_ @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma We talk about utilizing ALL aspect of therapy. When we talk about “combo”therapy, nutrition is an appropriate adjunct especially with #Crohns and often optimizers existing therapies.

@GutMD_ @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma My $0.02/take home points when approaching pts with #VEOIBD & those with have refractory disease: -think about your immunology and genetic colleagues when patients aren’t responding despite multiple therapies -history taking is key -remember the impact of diet

@SCKimIBDMD @MondayNightIBD @DCharabaty @abbvie @JNJInnovMed @TakedaPharma This is such an important caveat! Nutrition as adjunct therapy is one of the most imprtnt tools in peds #IBD. Pre-op surgical optimization, combo with biologics, & maintenance support, the data is there. The key is knowing when and how to deploy it 🎯 #MondayNightIBD #PedsGI

@DCharabaty @GutMD_ @MondayNightIBD @abbvie @JNJInnovMed @TakedaPharma @DLeVine901 @pdxIBD @BenjamminGold @dziring @DrRosenIBD @SCKimIBDMD @rafeeq_rm @PLLU @johnmrosen @DrChrisMoran @pedsgidoctora @GIJax_pedGI @nhaskeyRD @GIdietitian @pricetedwards @JeremyAdlerMD @sabpeds @drjshapiro @JenniferLeeLee1 @temarahajjat @DrNancyFu Avoid steroids at all costs. Would push CDED + PEN phase 1 (90% EEN if severe malnutrition). Def needs Imm eval: QUIGs+ response to vaccines, NADPH+, T&B flow, genetics. ⬆️10/kg ifx if -CGD. Goal TL >20. Consider combo Il23+Upa. May need diversion ileostomy.