Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?
There is not a clearly defined role for adjuvant sorafenib following locoregional therapy for HCC. The two main prospective randomimzed trials that inform this recommendation are:- The SPACE trial (Lencioni et al, J Hepatol 2016) -- no improvement in TTP when DEB-TACE was followed by sorafenib vs pl...
Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?
This is an excellent question. Most of the clinical trials with checkpoint inhibitors required complete taper of steroids prior to rechallenging wtih immunotherapy following toxicity. As we use immunotherapy in the clinic, and have utilized combinations with chemotherapy, including regimens that use...
Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?
I have done that is recent patients, yes. I am doing it because "on paper" I see better PFS and better ORR, of course in addition to the non-inferiority when compared to sorafenib in the randomized trial that is now published. However, I am building experience with respect to tolerance in my particu...
How do you manage venous thromboembolic events or bleeding events in RCC or HCC patients on anti-angiogenic TKIs?
I generally would not discontinue for a bleeding event for an RCC pts on anti-VEGF therapy. I may hold drug while managing the event if I can control the source of bleeding, but given most options include such an approach would restart cautiously. Similarly for venous thrombotic events I would manag...
Do you hold pelvic radiation for patient with clostridium difficile-associated diarrhea?
No. I proceed with radiation unless the diarrhea is not treatable with fluids and treat the C difficile with antibiotics. I am not aware of any data showing worsened toxicity of radiation concurrent with C difficile infection.
Are you routinely using thrombopoietin agonists in patients with hep C and HCC?
Thrombocytopenia is a common issue in patients with advanced liver disease due to decreased thrombopoietin production and hypersplenism sequestration from portal hypertension. The degree of thrombocytopenia is often a maker of both severity of liver disease.There are several TPO agonists on the mark...
Do you utilize EUS to determine the nodal radiation fields in esophageal adenocarcinoma?
Assuming that the primary lesion is PET avid, I would not hold up therapy for EUS. If the patient clearly needs to be treated for locally advanced disease, the only question is whether the fields need to be modified. EUS is better than CT (or PET CT) in determining the precise T-stage, especially fo...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...