Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
How do you manage patients on atezolizumab/bevacizumab with advanced HCC who develop arterial thrombosis?
I would stop bevacizumab if there is arterial thrombosis and start anticoagulation, continue single-agent atezolizumab. Would not stop the bevacizumab for portal vein thrombosis as it is most of the time a tumor thrombus.
For patients with HCC receiving atezo/bev, would you advise any other clinical investigations scheduled during treatment other than basic lab monitoring?
In the IMBrave 150 study, the most common serious toxicity in the AB arm was GI bleeding. And everyone was required to have their varices both evaluated and treated. It’s not convenient, but get the EGD before starting treatment!
Is anticoagulation a relative contraindication to atezolizumab/bevacizumab for advanced HCC?
Anticoagulation is considered safe with bevacizumab unless the patient has an increased of bleeding; as such, any varices should have been adequately treated before treatment with atezolizumab/bevacizumab; I would also avoid anticoagulation and atezo/bev concurrently in patients with platelet count ...
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
Would you use an IL-17 inhibitor for a psoriatic arthritis patient with inactive inflammatory bowel disease?
It depends on the options. While I would generally avoid using an IL-17 inhibitor in a patient with a h/o IBD, if there are no other reasonable treatment alternatives, and the IBD has been inactive for a significant period of time (a year?), then I would consider it, after a full discussion of the r...
What is your preferred second line therapy for an HCC patient who progressed after first line checkpoint inhibitor monotherapy?
After progression on immunotherapy monotherapy, assuming the patient is still eligible for further therapy and VEGF inhibition, I will move to a VEGF TKI. While the data supports the use of lenvatinib or sorafenib in the front-line setting (REFLECT and SHARP trials), I will use one of these agents (...
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
Would you recommend aspirin 600 mg daily for two years to a patient with Lynch syndrome and a history of colon cancer based on the results of the CAPP2 study for cancer prevention?
Yes, I would recommend this, with some caveats/considerations. 600 mg of aspirin daily x 2 years was the dose/duration shown to be effective in CAPP2--recently updated outcomes data from this trial (Lancet 2020) demonstrated an IRR of 0·50 (0·31–0·82; p=0·0057) for CRC among participants who were ab...