Management of Inflammatory Bowel Disease in the Caribbean

Abstract

Introduction: Inflammatory Bowel Disease (IBD) has been reported in several islands of the English speaking Caribbean. Limited resources in the region may affect the clinical management of the disease. We report the management preferences of physicians practicing in the English speaking Caribbean. Methods: Members of the Association of West Indian Gastroenterologists who currently practice in the Caribbean were sent on online survey. Members were asked a series of questions about their training and experience and random questions about their practice habits when managing patients with Ulcerative Colitis (UC) and Crohn's Disease (CD). The survey consisted of 30 questions. Each member was allowed one response. All responses were kept confidential. Results: Sixteen physicians responded to the survey. Twelve were practicing in the Caribbean at the time of the survey. Of those physicians; 5 practiced in Jamaica, 3 in Bahamas, 2 in Barbados, 1 in Trinidad and Tobago and 1 in Bermuda. Physicians were asked about their use of non-invasive markers of intestinal inflammation. Seventy five (75%) of physicians did not utilize fecal Calprotectin and fecal Lactoferrin to monitor their patients with IBD, although its use may prevent the need for costly endoscopic procedures. When initiating thiopurines, 63% of physicians ordered thiopurine methltransferase (TPMT) enzyme activity testing and 56% utilized thiopurine metabolite levels when evaluating dosing efficacy. Patients diagnosed with long-standing (> 10 years) pancolitis, in clinical remission, were routinely offered surveillance colonoscopies every 2 years, with a minority of physicians (25%) opting for every 3 years. Physicians were just as likely to perform random biopsies of the entire colon (40%) versus four quadrant biopsies every 10 cm (46.7%) when performing surveillance colonoscopies in patients with long standing UC even though chromoendoscopy is not widely available. Only 37% of IBD patients starting immune suppressive therapy are routinely vaccinated. While the majority of physicians (75%) will start 5-aminosalycilic acid (5-ASA) derivatives as initial therapy for mild to moderate UC, 41% will add steroid therapy for a clinical relapse before escalating therapy. Only 12.5% of physicians do not start immunomodulaters when initiating biologic agents. When there is a diminished response to biologics, most physicians will first check for antibodies (40%), before either increasing the dose (26.7%) or shortening the interval (20%). When patients hospitalized for a flare, prophylactic anticoagulation for deep vein prophylaxis is commonly initiated (60%). Conclusion: The earliest reports of IBD in the Caribbean were published in 1979 by Professors Courtenay Bartholomew and Alan Butler in Trinidad and Tobago. Since then epidemiological data has also been reported in Jamaica and Barbados. This is the first report, that we are aware of, describing the practice habits of physicians that manage IBD in the Caribbean. The management of IBD can be expensive, and heavily influences the clinical decisions that a physician must make. Those cases of moderate to severe disease, particularly in young people, that would warrant the use of biologic therapy, must often be treated with Thiopurines and steroids. Suboptimal treatment is less likely to result in sustained remission which translates in to frequent relapses, hospitalizations and surgery, all of which places greater demands on limited resources. More long term data is needed to determine outcomes so that resources can be better utilized to prevent sequelae of inadequately treated disease.