FRIDAY, NOVEMBER 7, 2014 RITZ-CARLTON HOTEL, TORONTO17

CASE-BASED WORKSHOPOptimizing Management Using CRP, Fecal Calprotectin and Ferritin

A 35-year-old male has had endoscopically and histologically con!rmed ulcerative pancolitis for 7 years. At the time of diagnosis (2007) his CRP was 65 and he was initially treated with mesalamine 4.8 gm/d plus 30 days of rectal mesalamine and a tapering course of prednisone beginning at 40 mg and tapering to zero over 14 weeks. He rapidly went into a clinical remission and eventually reduced his mesalamine to 2.4 g/d maintenance therapy.

He lives 7 hours from a major metropolitan centre and has had his mesalamine prescription renewed by his family physician over the years.

He is newly married and his wife arranges a follow-up appointment with your o"ce.

On history in your o"ce he states he is well and asymptomatic. He has one more bowel motion per day than normal with no blood equating to a partial Mayo score of 1, indicating full remission.

Laboratory testing reveals the following: Normal Hemoglobin, MCV and platelets Ferritin 12 (12-300) Iron 9 (10-30)

The rest of his laboratory investigations are normal.

ARS Decision Node1. Does this gentleman need further investigation?

Yes No

2. Which tests would you do?

a) Peripheral smear Yes No

b) Bone Marrow aspiration Yes No

c) Stool O&P and culture Yes No

d) Stool C. di!cile toxin assay Yes No

e) ESR Yes No

f ) CRP Yes No

g) Fecal Calprotectin Yes No

You order a CRP and fecal calprotectin: CRP = 18 (1-8) Fecal calprotectin = 356 (

FRIDAY, NOVEMBER 7, 2014 RITZ-CARLTON HOTEL, TORONTO 18

ARS Decision Node3. Given the patient is asymptomatic and has a partial Mayo

score of 1, do you need to act on the CRP and FCP results? Yes No

You decide to have him drive 7 hours back to see you for a colonoscopy. The colonoscopy demonstrates loss of vascular pattern and granularity up to 35 cm, loss of vascular pattern only with no granularity from 35 to 65 cm and a normal endoscopic picture from 65 cm to the cecum. The ileum is normal.

ARS Decision Node

4. Based on the lab and colonoscopy !ndings, would you escalate his therapy? Yes No

5. If you were to escalate therapy, what would you use?

a) Mesalamine oral Yes No

b) Mesalamine rectal Yes No

c) Corticosteroids oral Yes No

d) Corticosteroids rectal Yes No

e) Azathioprine Yes No

f ) Anti-TNF Yes No

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________