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Nurses must educate in IBD treat-to-target, considering patient’s goals
ORLANDO, Fla. — Nurses caring for patients with inflammatory bowel disease must translate goals of medical treatments as well as educate patients on treat-to-target and the monitoring of their medications, but not lose sight of the patient’s own goals, according to presenters at Advances in IBD 2017.
“There’s many options for monitoring disease. Our gain is that there’s less guess work. This can help guide clinical practice and help patients understand what’s going on for them. One size does not fit all. The role of the nurse is education education and follow-up labs and communication with the patient,” Anne Bobb, BSN, RN, a nurse navigator at the Penn State Hershey IBD Center, said during her presentation. “Objective evidence of disease and markers are critical to improving IBD care. Laboratory monitoring will likely become ever more important.”
Bobb said nurses must understand the target, whether it be quality of life, laboratory remission, endoscopic remission or another goal set by the provider.
“We are looking at all of that. There really isn’t a consistent definition” of treat-to-target, she said.
Bobb covered different measurements that nurses and physicians can use in managing IBD: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR); fecal calprotectin; thiopurine metabolites; and therapeutic drug monitoring.
CRP and ESR
In regard to CRP and ESR, Bobb said a nurse in an IBD practice must educate the patient that these are nonspecific measurements and may respond to other inflammation in the body. Additionally, she said not all patients respond in the same manner and some may never have abnormal levels despite having more severe disease.
“It’s important to know how your patient launches the inflammatory response. Do they mount these numbers or do they not? If they don’t, it’s not really a helpful tool for you,” Bobb said. “If they perform well, then that would be consistent for you and that would be a marker you could use consistently through the care of the patient.”
She said something as unrelated as gum inflammation can throw off the values and nurses must educate patients as to the values they are seeing in the patient portal.
“It’s not specific to the GI tract,” she said. “We really need to correlate what’s going on clinically with our patient with the lab values. We always need to be looking at our patients and what’s going on with them.”
Fecal calprotectin
“It’s going to tell you there’s inflammation in the GI tract, but not how much. Extent of disease is not going to be identified with fecal calprotectin,” she said. “The nurse’s role when we look at fecal calprotectin is education, education, education.”
Part of that education is giving the best instructions for the patient’s stool sample to best measure the fecal calprotectin, Bobb said. It should be the first stool of the day and at least 3 days after a colonoscopy. The stool can be stored for up to 3 days, but the sooner the patient turns it in, the better, she said.
Thiopurine metabolites
When discussing thiopurine metabolite monitoring, Bobb said it comes down to “labs, labs, labs” since the patient will undergo pretreatment testing to determine how he or she metabolizes the drug and to confirm safety for this patient.
“At the end of the day, we want to talk about how this drug is metabolized and what we’re looking for,” Bobb said. “This is a target that does lead to changes in therapy.”
Patients should also understand that this will indicate compliance as well as efficacy, she said. An IBD nurse should also be aware that the weight of the patient affects the efficacy of the drug and, therefore, dosing must change with any fluctuation in weight.
Therapeutic drug monitoring
“Our goal with therapeutic drug monitoring is to optimize care, improve efficacy, safety and cost-effectiveness of the drug. We are trending toward proactive vs. reactive,” she said. “It’s treat-to-trough. We are looking at the trough level to see where we can go with that patient.”
As nurses in IBD practices, Bobb said they need to understand that there are factors that will affect the numbers — sex, BMI, malnourishment, high CRP or disease activity, high baseline tumor necrosis factor and a presence of antibodies — and the timing of the monitoring should truly reflect the trough.
“When we get the results, we have to look at interpretation,” she said. In looking at the drug levels and antibody presence, providers must balance next steps carefully.
“We know we don’t have 30 drugs in our arsenal,” Bobb said. “I’ve seen my providers push to keep patients on therapy that’s had success ... to try to keep that drug on board. ... This is where it becomes a chess game.”
All about the patient
In the end, Bobb said the target that every IBD nurse should have in mind when discussing medications and monitoring with their patients is that of the patient in front of them.
“It’s great we have all this data, but we can’t forget the patient,” she said. In daily practice, she says to patients: “You tell me what’s your target.” When the patient says her target is a baby or his
is to enjoy life without daily pain, then the medication targets become more clear, Bobb said.
“We all know what stress does to our IBD patient and how that can negatively impact their quality of life and their experience. The nurse’s role in helping to alleviate stress is our opportunity to educate,” Bobb said. “Data is wonderful, but at the end of the day, these are our patients and really they are the target.” – by Katrina Altersitz
Reference:
Bobb A. Session IVB: Interprofessional IBD Patient Management. Presented at: Advances in IBD; Nov. 9-11, 2017; Orlando, Fla.
Disclosure: Bobb reports she is on the speakers bureau for Pfizer.