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Manage IBD Aggressively Before Liver Transplantation

Summary and Comment |
September 17, 2013

Manage IBD Aggressively Before Liver Transplantation

  1. Atif Zaman, MD, MPH

This and other approaches will help control IBD during and after transplantation as well.

  1. Atif Zaman, MD, MPH

The management of inflammatory bowel disease (IBD) before and after liver transplantation is complex in patients with primary sclerosing cholangitis–related cirrhosis. A recent study observed that patients with IBD had better control of their colitis posttransplantation if they were on cyclosporine and azathioprine versus tacrolimus and mycophenolate mofetil (NEJM JW Gastroenterol Jun 26 2013). Now, based on a review of state-of-the-science data, researchers suggest approaches for optimal patient management in this complex setting, as follows:

Pretransplantation:

  • Optimize treatment of IBD.

  • Refer patients with refractory IBD to surgery in a timely manner prior to the development of cirrhosis.

  • Conduct annual colonoscopy for surveillance of neoplasia.

Peritransplantation:

  • Avoid discontinuation of 5-aminosalicylate products.

  • Counsel patients on smoking cessation.

  • Consider concomitant colectomy at time of liver transplantation in patients with aggressive IBD.

Posttransplantation:

  • Consider a tacrolimus-free regimen.

  • Add azathioprine to the immunosuppression regimen.

  • IBD flares can be managed safely with 5-aminosalicylates, steroids, and immunomodulators.

  • Anti–tumor necrosis factor α agents are effective, but careful monitoring for infections, autoimmune disorders, and malignancy is required.

  • Cytomegalovirus infection can trigger de novo IBD.

  • Patients with pouches are at high risk for acute and chronic pouchitis and should be managed aggressively.

Comment

This valuable review highlights the complex nature of inflammatory bowel disease management after liver transplantation for primary sclerosing cholangitis. To maximize IBD control posttransplantation, clinicians should be aggressive in disease control pretransplantation. In addition, avoiding discontinuation of 5-aminosalicylate products at the time of transplantation and avoiding the use of tacrolimus-based regimens will further improve IBD outcomes posttransplantation. Finally, annual surveillance colonoscopies are important, since colon cancer risk is high after liver transplantation.

  • Disclosures for Atif Zaman, MD, MPH at time of publication Speaker’s bureau Bristol-Myers Squibb; Genentech; Gilead; Kadmon; Merck; Salix; Vertex

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