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Gastroenterologist Shamita B. Shah discusses her article, “How doctors can help IBD patients manage symptoms between visits.” Addressing the rising prevalence of inflammatory bowel disease (IBD) in the U.S., Shamita highlights the challenges patients face managing unpredictable symptoms like pain and diarrhea, even while on therapy, often leading to undertreatment and complications. She outlines three key ways physicians can empower patients for better self-management between appointments: First, engaging patients to track symptoms using tools like wearable devices or digital platforms incorporating patient-reported outcomes (PROs), citing studies showing these methods can predict flares and significantly reduce emergency room visits (by 48 percent) and hospitalizations (by 78 percent). Second, educating patients on the diet-disease connection, recommending approaches like the Mediterranean diet and the use of food diaries (potentially via apps) to identify individual triggers. Third, providing patients with a comprehensive health maintenance checklist, such as the one from the Crohn’s and Colitis Foundation, to ensure accountability for crucial screenings (cancer, mental health) and vaccinations, especially important for those on immunosuppressive therapies. Actionable takeaways focus on physicians proactively equipping patients with these tracking tools, dietary guidance, and checklists to foster better disease control and quality of life.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Shamita B. Shah. She’s a gastroenterologist, and today’s KevinMD article is “How doctors can help inflammatory bowel disease patients manage symptoms between visits.” Shamita, welcome to the show.
Shamita B. Shah: Well, thanks for having me. I’m very excited to be here today. And I’m looking forward to talking to you a little bit more about the article that I wrote and also how we can enhance IBD care in general.
Kevin Pho: All right, so before we do that, just briefly share your story and journey.
Shamita B. Shah: My journey: I’ve been doing inflammatory bowel disease as a specialist for Crohn’s and colitis for approximately 15 to 17 years now. I started with this; I have an interesting story, mainly because it was my father who has driven a lot of my passion. He was unfortunately mismanaged, had this disease, had complications, and passed away. And so, a lot of what drives me in my career is really to see if we can deliver the best care we can to these patients so that they don’t have poor outcomes.
Kevin Pho: All right, so tell us about the article for those who didn’t get a chance to read it. It’s titled “How doctors can help inflammatory bowel disease patients manage symptoms between visits.”
Shamita B. Shah: I’ve learned a lot through my journey with my career also, Kevin. I was a clinical director of IBD on the West Coast at Stanford for a while, and now I am the clinical director here at Ochsner, and I think both of those have made me open my eyes to how to deliver care in different areas of the country. And also, I’ve learned a lot through that.
The article primarily focuses on the growing number of patients with this disease, and it’s a chronic disease. As you know, chronic diseases have a lot of disease burden. These patients have diarrhea, rectal bleeding, they’re fatigued, they have weight loss. And so, we get a very focused time point when we see them in the clinic. But what happens to them between those visits? And how do we engage the patient to track their symptoms and what can we do to help them with that?
Now, there’s more and more technology to help patients with that, whether we’re talking about computer-interfaced IBD monitoring platforms. There’s also wearable technology that’s been shown to be helpful to track flare-ups for these patients between visits. Patients forget what happened in the last six months, the last 12 months between their visits. And so, there are ways for them to document what’s happened to them in that timeframe and when to escalate the need to see a physician. The other thing is diet plays a big role in inflammatory bowel disease. How do these patients track their diets and create food diaries?
And that’s where technology can also be very helpful. We have checklists to allow for patient accountability, for example: Did you get your vaccines? We use a lot of medications that can suppress their immune system, and so getting your vaccines to prevent infections is going to be very important, especially those seasonal vaccines.
So, I think this article is just highlighting that we have to think of IBD care in a different way now. Times have changed. Times have changed in all fields, but in the last 10 years, the number of medications and advanced therapies we have makes us have to change. And the growing number of patients, really.
Kevin Pho: So in general, as a gastroenterologist, how often do you see patients with chronic symptoms from IBD? And what do you do with this trove of information when patients come to you with these diaries, whether it’s remote monitoring? Give us a scenario, story, or an example of how you would use this data during a visit.
Shamita B. Shah: We’re working on several things right now in our clinic regarding how to monitor them between visits. One of the things is that if they come in with symptoms, those patients who are having active symptoms and not doing well, they are going to be seen more often. OK.
Those patients that are in deep remission, doing well, are adherent to their medications, and are communicative with the care team when something’s not right, those patients may be seen less often. But within that, I think that we’re using some EHR platforms, including using our EHR in ways that we’re utilizing our nurses in a different way.
They have patient panels that we are going to be building so that they can check in with the patient. We have clinic-based pharmacists that help as extenders into my clinic, and that’s been very helpful to monitor them in between their visits. But there are also other platforms out there. As I mentioned, there’s wearable technology that we’re looking at. But also there are computer-based platforms like SonarMD; that is one of them. There are some others out there as well. I think it’s important to identify which patients go down which track or how you manage each patient, depending on their disease activity and other social factors as well.
Kevin Pho: And what specific symptoms or patient reports are you looking for to perhaps bring them in for more acute treatment?
Shamita B. Shah: Mainly abdominal pain, diarrhea, weight loss, fevers; those are probably the most common. Some more subtle things are like bloating, or something’s changed, or they’re more tired all of a sudden. But generally GI symptoms.
Kevin Pho: You mentioned in your article that there are studies that show reduced emergency department visits for people who monitor symptoms.
Shamita B. Shah: Absolutely. So, for example, the computer-based platform and some of the wearable technology, they are really at the forefront of technology, and they have been shown that if you can monitor these symptoms early, then you can prevent ER visits, hospitalizations, and decrease not just cost of care, but really improve the patient’s quality of life so that they can go to work, because there’s a lot of missed work and missed school. This disease population often affects people at a younger age, often when they’re 18 to 35 years old, or 50 years old. And so, by controlling their disease, they have better quality of life and can go on with their life.
Kevin Pho: You mentioned earlier that diet plays a large role in terms of potential triggers for IBD, so talk more about that. What are some things that patients could do themselves to potentially reduce the incidence of flare-ups?
Shamita B. Shah: Absolutely. So there’s the DINE study, which is one of the studies that were done that actually was a randomized control trial between the Mediterranean diet and the specific carbohydrate diet. But the premise of most of these diets is really important. Some very simple things that patients can do is decreasing the amount of sugar that you’re eating.
Eat less processed foods. The Mediterranean diet seems to have a lot of data and a lot of evidence that can be helpful, not just for inflammatory bowel disease, but also cardiac disease, as we know. So these are some small things, but keeping a food diary so that if you’re not feeling well after a certain food, then maybe reevaluate that and bring that up to your physician when you go to their visit so that they can help guide you.
Kevin Pho: You mentioned the importance of vaccines because a lot of these patients sometimes are on immunomodulator therapy. So give us a sense of any additional vaccines, or is it simply sticking with the typical adult recommendations? Give us a sample of the vaccine schedule.
Shamita B. Shah: Sure. So beyond the regular vaccine schedule, when somebody has a low immune system from medication that we’re giving, whether you’re a transplant patient or an inflammatory bowel disease patient, it is recommended that you get a pneumonia vaccine and shingles vaccine before the age that it’s indicated. We recommend the RSV vaccine, flu, COVID, tetanus, just the regular schedule. But we also are very particular about HPV and making sure we discuss HPV vaccinations with our patients as well. One of the things that I want to emphasize is no live vaccines should be given. So if you’re on immunosuppression, you cannot get any live vaccines. The other thing is that it’s important to vaccinate them before they get immunosuppressed if you have that opportunity because they mount a much better response to the vaccine if you do it before they’re immunosuppressed.
Kevin Pho: So we’ve been talking about a menu of options that patients can use to monitor their own symptoms. Sometimes the amount of choices can be overwhelming. So let’s say we have a newly diagnosed patient with inflammatory bowel disease. What do you typically recommend to start off with in terms of monitoring some of their symptoms?
Shamita B. Shah: I think symptoms-wise, you just want to see where your baseline is and then when you’re well and you’re in remission, what changed? For mostly many patients, it’s abdominal pain and diarrhea. I think the most important thing is to ask a lot of questions. Patients need to ask questions of their providers. They need to know what their options are because there are so many more options, even in the last five years. We’ve doubled the number of drugs that we have available. So it’s important to know that you have options and it’s not just whatever was available 20 years ago. We have to move with time and offer patients less risky medicines that are more effective. And that’s what we’ve done over the years.
I think the other thing is that patients really need to understand where their disease is in the intestine and the type of disease they have: whether they have any complications or outside-of-the-bowel manifestations of their inflammatory bowel disease. As we know, inflammatory bowel disease can affect the joints, the skin, the eyes. So it’s important to understand your disease phenotype.
Kevin Pho: So sometimes as a primary care physician, I see patients, of course, in between visits with a gastroenterologist. Now, are there any specific questions that I should be asking or any symptoms I should be looking out for when I see these patients in a routine visit, in between their GI appointments?
Shamita B. Shah: I think there are three aspects to this. So one aspect: One thing you can do is ask about symptoms like how many bowel movements? Have you noticed any changes in your bowel habits? And it could be very subtle changes in the consistency or the frequency. Waking up in the middle of the night with any bowel movements? Any blood in your stool? Abdominal pain: where is it, and is it associated with their IBD or not?
The second aspect, as a primary care physician, that you can do is biochemical monitoring. What I mean by that is looking for anemia when it doesn’t make sense. Iron deficiency anemia may be an indicator of active disease. Inflammatory markers, CRPs, which we use a lot of, and obviously if it’s specific for the disease and not something else. And then the other thing is a stool calprotectin test, which is a stool biomarker that is more specific for inflammation of the gut. That’s a very good way to closely monitor the disease non-invasively without a colonoscopy.
And then the third aspect is cancer screening and IBD health maintenance. Pap smears, mammograms, yearly skin exams because patients with IBD are at higher risk for skin cancer as well. And then the vaccines, of course, that we already talked about.
Kevin Pho: You mentioned you work for Ochsner as well as Stanford, major academic medical centers. I was talking to a specialist yesterday about the geographic disparity because a lot of the things that we talk about and are talking about today, like remote patient monitoring, are often only available to large urban centers or academic medical centers. What about those patients in rural settings where seeing a gastroenterologist may take a couple hours’ drive and they may not have those technologies available? Talk a little bit about the geographic disparities that sometimes you see when it comes to monitoring IBD patients.
Shamita B. Shah: I’m really glad you asked that question because I think over my career, that’s one thing I didn’t understand fully in the beginning of my career and I understand much better now. I did my training in Chicago at the University of Chicago and that was very different: The Midwest population versus the West Coast versus the South population. And many people come from all over the Gulf South over to Ochsner to be seen. But I think patients’ education, their diet, how they function in their community… Their education… you have to factor all of those things in because that determines what medicine you are going to give them, believe it or not, or how you are going to treat them. And my patient population in California and Palo Alto is very different from New Orleans, Louisiana. Their priorities in life are different, as is their availability to access to care, as you said.
This is where I think technology has helped us a lot because we’re able to deliver care virtually: audio visits, video visits. That’s one of the best things that happened, in my opinion, during COVID is that we were able to deliver care to a greater number of patients. My group actually got our licenses covering Louisiana all the way to Florida. So we have licenses in Mississippi, Alabama, and Louisiana. And so we’ve been able to use that digital platform to deliver care to these rural areas.
Kevin Pho: So you mentioned sometimes the patient population can really affect, sometimes even the medications that you prescribe: West Coast versus the South. What would be an example of that?
Shamita B. Shah: I think what I’m talking about is not just what their insurance is and what the cost of care is, but also what their beliefs are and what risks they’re willing to accept. So I think that on the West Coast, for example, I definitely saw more patients wanting to do more alternative, complementary medicine. Sometimes it was definitely evidence-based and it made sense, and sometimes it didn’t. And here, some patients don’t even have access to care. We see uninsured patients on call, for example, and you think, “How do I get them their care?” I’ve done things like making phone calls with patients who didn’t have care until they got Medicaid. Things like that. So it’s interesting to see how you have to change your practice as a physician based on where you are and what your patient population is. I don’t think people understand that. So what works over there doesn’t always work over here.
Kevin Pho: So let’s take a step back. In general, what’s coming on the horizon when it comes to managing inflammatory bowel disease patients? Anything that we have to look forward to?
Shamita B. Shah: Yes, a lot. I think we have way more advanced therapies now available, which makes it a better playing field for patients. We have so many options and so many low-risk options as well, and effective options. So that’s exciting because when I trained, there were only a few drugs, and now there are so many more.
The other things that are more exciting is the technology, and that’s what my article highlights, just coming back to that: how do we embrace this technology to deliver care to a greater number of patients in a different way? And if we don’t rethink how we do things… We all know that there’s a huge shortage of doctors—up to 125,000, they’re predicting by 2030. GI is one of the biggest subspecialties that is going to be deficient. So how do we use technology to deliver care better and more effectively to a greater number of patients?
Kevin Pho: We’re talking to Shamita B. Shah. She’s a gastroenterologist. And today’s KevinMD article is “How doctors can help inflammatory bowel disease patients manage symptoms between visits.” Let’s end with some take-home messages that you want to leave with the KevinMD audience.
Shamita B. Shah: A couple lessons just for the clinical audience are that for those of you who are already thinking about revamping how you approach chronic disease care, it’s worthwhile to engage with your own organizational leadership to discuss your vision and also have them help you break down the walls of the traditional ways of delivering quality care to patients. And I think the take-home message also is that we know this is a chronic disease. It’s difficult to manage ulcerative colitis and Crohn’s disease, and it affects patients in so many different ways. We can help our patients by focusing on patient education and giving them tools to help manage their disease in between appointments. As a group, we really need to utilize technology to help deliver that quality care to more patients who need it.
Kevin Pho: Shamita, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Shamita B. Shah: Thank you so much for having me.
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