Update IBD management vietnam

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Incidence of IBD in Hong Kong: 1980201430fold increase in three decadesHK IBD RegistryIncidence of IBD in Hong Kong: 1980201430fold increase in three decadesHK IBD RegistryIncidence of IBD in Hong Kong: 1980201430fold increase in three decadesHK IBD RegistryIncidence of IBD in Hong Kong: 1980201430fold increase in three decadesHK IBD Registry Updates in IBD Management Siew Ng MBBS, FRCP (Lond, Edin), FHKAM, PhD (Lond) Professor Department of Medicine & Therapeutics Copyright © 2016 All Rights Reserved Faculty of Medicine, The Chinese University of Hong Kong Chinese University of Hong Kong The Global Map of IBD in 2015: IBD is a modern disease of modern times that is rooted in the industrialization of society Incidence of IBD is 30 per 100,000 Incidence of IBD is 7,000,000 in 2013 Hong Kong IBD Registry, N=3,000 NTE Cluster, North District Hospital (NDH) NTW Cluster, Tuen Mun Hospital (TMH) and Po Oi Hospital NTE Cluster, Alice Ho Miu Ling Nethersole Hospital (AHNH) NTE Cluster, Prince of Wales Hospital (PWH) KW Cluster, Prince Margaret Hospital (PMH) and Yan Chai Hospital KE Cluster, Tseung Kwan O Hospital (TKOH) KW Cluster, Caritas Medical Centre (CMC) KE Cluster, United Christian Hospital (UCH) KW Cluster, Kwong Wah Hospital (KWH) KC Cluster, Queen Elizabeth Hospital (QEH) HKW Cluster, Queen Mary Hospital (QMH) HKE Cluster, Ruttonjee Hospital (RH) HKE Cluster, Pamela Youde Nethersole Eastern Hospital (PYNEH) Incidence of IBD in Hong Kong: 1980-2014 30-fold increase in three decades HK IBD Registry per 100,000 0.1 per 100,000 Ng SC et al Inflamm Bowel Dis 2016 Prevalence of IBD in Asia & the West UC CD India Seoul Japan Hong Kong 1984 2005 2003-2005 2011-2013 43.0 30.9 57.3 34.0 11.2 18.6 21.0 North America North Europe United Kingdom New Zealand 2001 1987 1996 2004 246 161 122 155 162 54 214 104 Ratio of Ulcerative colitis : Crohn’s disease Ulcerative Colitis Crohn’s disease UC/CD Ratio 7.33 14.00 0.5 2.22 1.22 1.8 1.66 1.31 1.2 Macau 1.00 0.60 1.7 Sri Lanka 0.95 0.61 0.59 0.40 1.6 1.5 0.59 0.24 2.5 0.55 0.33 1.7 0.36 0.30 1.2 0.35 0.28 1.3 0.43 0.14 3.0 0.42 0.07 6.0 Country Australia Mainland China (Guangzhou) Hong Kong Singapore Malaysia Indonesia Thailand (Chiangmai) Thailand (Bangkok) Mainland China (Chengdu) Mainland China (Xian) Ng et al Gastro 2013 Natural History of Ulcerative Colitis with Standard Therapy Percent of Patients 100% 90% 80% 70% 60% Colectomy Disease activity Remission 50% 40% 30% 20% 10% 0% 10 12 14 16 18 20 22 24 Years After Diagnosis *Percent of patients with disease activity, in remission, or having colectomy performed each year after diagnosis Langholz E et al Gastroenterology 1994;107:3 The way we practice in UC… Surgery Inpatient IFX CsA or IFX IV steroids IFX Outpatient AZA/6-MP Oral steroids Aminosalicylates 6-MP, 6-mercaptopurine; AZA, azathioprine; CsA, ciclosporin A Adapted from: Rogler G Dig Dis 2009;27:542-5 When to Start Anti-TNF Patients with adverse prognostic factors (younger, perianal lesions, extensive SB disease, stricturing disease, deep colonic ulcers, multiple resections) should be started on biologics (± immunosuppressants) Conventional Therapy with Accelerated Step-up Rapid transition Moderate Crohn’s disease No Adverse Prognostic Factors Steroids No remission 4-6 weeks Thiopurine/methotrexate ~40% achieve remission at year No remission 3-6 months Start anti-TNF therapy and continue thiopurine The Anti-TNF Antibodies in CD One year Remission ACCENT 1, Hanauer et al Lancet 2002 CHARM, Colombel et al Gastroenterol 2007 PRECISE 1-4, Schreiber et al NEJM 2007 Initial Responders All Treated Patients Infliximab (ACCENT 1) 39% 23% Adalimumab (CHARM) 36% 21% Certolizumab (PRECISE & 3) 42% 27% Loss of Response to Biologic Kamm, Ng et al IBD 2011 Luminal Crohn’s disease (with or without perineal fistulas) Scheduled regular anti-TNF therapy and thiopurine Loss of response oral steroid Increase dose of anti-TNF Reduce dose interval of antiTNF Temporarily increase dose of anti-TNF Switch to different biological drug Modern Management of Fistulising Crohn’s Disease If complex fistula and active rectal disease seton only The “21st Century” Management for Crohn’s Perianal Fistulas Fistula closure as a therapeutic goal Early use of biological therapy Role of imaging in monitoring treatment Combined medical and surgery treatment Assessment of Fistula EUA MRI / AES ENDOSCOPY To include surgical drainage and/or seton To delineate fistula anatomy, extent and relationship of tracks to sphincter muscles To assess proximal disease & extent of rectal disease This should really be current practice Axial MRI Trans-sphincteric fistula with supralevator extension Not healed on MRI despite external opening closure Before Infliximab 34 weeks after Infliximab Coronal MRI Trans-sphincteric fistula with supralevator extensions Marked improvement with track resolution on MRI Before Infliximab 52 weeks after Infliximab Modern Management of Crohn’s Fistulas Kamm & Ng, Clin Gastro Hepatology 2008 Accurate anal imaging (MRI, EUA, Endoscopy) Drainage +/- seton Aggressively manage proctitis Anti-bacterial short term treatment AZA/6-MP first line Anti-TNF often needed Consider seton removal week 4-6 MRI at 12 months to guide treatment duration Don’t forget to optimise nutrition Summary: Ulcerative Colitis 5-ASA is first line treatment for mild-moderate UC Combined topical and oral preparation is superior to oral alone Improve adherence by once daily dosing Disease monitoring with fecal calprotectin guide treatment optimisation Mesalazine is associated with a reduced cumulative risk of cancer in UC Summary: Crohn’s Disease Scheduled anti-TNF superior to episodic treatment Early anti-TNF use for better efficacy Combination anti-TNF with thiopurine is the most effective (SONIC) Stronger and quicker induction is more effective (“Step up vs Top Down”) Can bridge to thiopurine and stop biologic (STORI) Cảm ơn ... Australia Mainland China (Guangzhou) Hong Kong Singapore Malaysia Indonesia Thailand (Chiangmai) Thailand (Bangkok) Mainland China (Chengdu) Mainland China (Xian) Ng et al Gastro 2013 Natural... (PYNEH) Incidence of IBD in Hong Kong: 1980-2014 30-fold increase in three decades HK IBD Registry per 100,000 0.1 per 100,000 Ng SC et al Inflamm Bowel Dis 2016 Prevalence of IBD in Asia & the... University of Hong Kong The Global Map of IBD in 2015: IBD is a modern disease of modern times that is rooted in the industrialization of society Incidence of IBD is 30 per 100,000 Incidence of IBD is
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