second opinion regarding the management of his ulcerative colitis

A 45-year-old Caucasian male presented to a gastroenterologist (GE)’s office for a second opinion regarding the management of his ulcerative colitis (UC) after a recent flare-up had prompted his prior physician to recommend that he consider the addition of alternative drugs and/or partial colectomy. The patient’s electronic medical records revealed a 15-year history of UC managed with ­­­­­­a low-dose oral 5-aminosalicylic acid (5-ASA) and twice-daily topical 5-ASA enemas, with the recent addition of oral glucocorticoid therapy 4 weeks ago. This was the second occurrence of oral glucocorticoid use for the induction of remission in this patient, the first being for a UC relapse 6 months prior. There was no mention of attempt with topical steroid use. According to previous endoscopy and biopsy results, the patient suffered from moderately active UC localized distally to the splenic flexure. His last colonscopy was 2 years prior to the present visit.

The patient denied the current presence of symptoms, including pain or bleeding. His urgency, tenesmus, and diarrhea had been relieved since the initiation of oral glucocorticoids 4 weeks ago. He had a follow-up appointment scheduled for 2 weeks thereafter, which he missed, but he assured the GE that he had been tapering the steroids as admonished. When prompted about his recent use of topical 5-ASA therapy in concordance with his daily oral 5-ASA therapy, issues of nonadherence arose, which the patient attributed to “personal reasons” that had developed over the past 2 years. Because the patient was reluctant to discuss these matters, the GE, at the request of the patient, tasked the nurse practitioner to meet with the patient afterwards.

On examination, the GE noted that the patient’s temperature was normal, and his weight was unchanged from 4 weeks prior. Signs of extraintestinal disease, including uveitis and arthritis, were absent. No blood or mucus was noted on digital rectal examination.

The patient’s records indicated that his baseline bone mineral density scores 3 months ago were within the normal range. In light of the patient’s current oral glucocorticoid use, the GE ordered a follow-up DEXA scan to be completed in 3 months to compare future values to baseline. The GE also ordered a routine colonoscopy to be performed within the next 2 weeks, as well as laboratory studies inclusive of CBC, CRP, ESR, and liver function tests.

After a discussion about UC medications and regimens, the physician and patient decided to increase the dose of the oral 5-ASA and to await the colonscopic results before deciding whether to switch from the enema preparations to a more tolerable form of topical 5-ASA therapy. Tapering of the oral glucocorticoids was continued.

Discuss Quality of Care with Performance Measures

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