‘New tools’ offer hope for diverse gastrointestinal symptoms in systemic sclerosis
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DESTIN, Fla. — Stepwise interventions, starting with diet and moving on to pharmacotherapies in more severe patients, is essential to managing gastrointestinal complications in scleroderma, a speaker said at the Congress of Clinical Rheumatology East.
“GI symptoms are diverse among patients with systemic sclerosis,” Zsuzsanna McMahan, MD, MHS, associate professor of medicine at Johns Hopkins University School of Medicine, said in her presentation. “Sorting through the complexity of a patient’s symptoms can be challenging in a 30-minute visit.”
However, as complicated as some patient cases can be, McMahan explained that the challenges are compounded by one more important factor.
“There is nothing officially approved for scleroderma GI disease yet,” she said.
In the absence of approved treatments, McMahan encouraged rheumatologists to consider some broad categories of problematic areas in their patients with scleroderma who have GI issues. Motility is one possible area of concern, along with the microbiome in the patient’s gut and dietary issues.
“The esophagus is impacted in 90% of scleroderma patients with GI issues,” McMahan added.
That said, the stomach, large and small intestines, and the rectum have all been known to be problematic areas in this patient population as well.
“Understanding where the problem is critical in determining medications and the approach to therapy,” McMahan said.
Starting at the mouth, Sicca symptoms are “often ignored,” but should not be, she added. Dry mouth can impact oral and dental hygiene, which can be, in turn, ultimately detrimental to nutrition.
Clinicians should also be aware of the possibility of oropharyngeal or esophageal dysphasia.
Perhaps the most common upper GI complication in SSc is gastroesophageal reflux disease (GERD), according to McMahan.
“The first line assessment is to start on proton pump inhibitors,” she said. “In patients who are hesitant about PPIs, start with an H2 blocker.”
If the patient is still not responding, that is considered refractory disease, in which case an upper endoscopy is warranted.
A “new tool” for GERD in these patients is vonoprazan (Phathom Pharmaceuticals), a potassium-competitive acid blocker medication, McMahan said. She added that early data from Japan indicate that this drug may be effective in scleroderma, but it has not yet been studied in the United States for that indication.
Buspirone is another option that is emerging in the treatment of scleroderma-associated GI disease.
“Buspirone has been around for a long time and has been used for anxiety and depression,” McMahan said. The drug is another in a trend of repurposed medications that manage nerves in the brain to manage nerves in the gut, she added.
Shifting gears, McMahan said bloating and early satiety can be present in many of these patients. Elimination diets are a good place to start with this issue. She recommended that patients eat small meals that contain little fat or fiber.
For issues in the lower GI tract, diarrhea is frequently reported in SSc populations. Although many clinicians would reach for an antibiotic such as metronidazole in this situation, McMahan offered an additional perspective.
“A week of antibiotics and a week of probiotics might help improve symptoms,” she said.
Conversely, constipation may also occur in scleroderma.
“You want to encourage fluids, exercise, and, if need be, over-the-counter medications,” McMahan said.
She noted that patients have reported improvement with interventions ranging from prunes to herbal tea.
For severe cases, linaclotide and lubiprostone are pharmacotherapeutic options to be considered in patients with scleroderma who are constipated.
“Remember to rule out the basics first, like diet and medications,” McMahan said. “There are many other things that can cause GI dysfunction in our patients.”
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McMahan Z. Evaluation and management of scleroderma GI disease. Presented at: The Congress of Clinical Rheumatology East; May 12-15, 2022; Destin, Fla.
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